Recovery-oriented practices and role perceptions of healthcare staff providing community-based mental healthcare as team in Central and Eastern Europe: an observational study

Recovery-oriented practices and role perceptions of healthcare staff providing community-based mental healthcare as team in Central and Eastern Europe: an observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Recovery-oriented practices and role perceptions of healthcare staff providing community-based mental healthcare as team in Central and Eastern Europe: an observational study Catharina Roth, Michel Wensing, Martina Rojnic Kuzman, Sarah Bjedov, and 18 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-215308/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: CMHTs deliver healthcare that supports the recovery of people with mental illness. They should achieve a sufficient level of good quality teamwork, composed of individual professional skills as well their adaptation within the clearly defined roles in teams in order to work efficiently. This paper analyses to what extent team members of five CMHTs newly implemented in five countries had introduced aspects of the recovery-oriented approach and evaluates what the team members’ perceptions on their collaborative care roles and their level of confidence with this role are. Method : A quantitative survey was administered among 66 professionals and peer worker including the Recovery Self-Assessment Tool Provider Version (RSA-P), the Team Member Self-Assessment Tool (TMSA), and demographic questions. Result: The RSA-P showed that all teams had the perception that they provide recovery–oriented practice to a moderately high degree after a training week on recovery-oriented care. Healthcare providers with fewer years of professional experience perceived more frequently that they operated in a recovery-oriented way (p=0.036, B -0.268). Nurses and peer workers did not feel confident or responsible to fulfil specific roles. Conclusion: Trainings on community-based practices and collaborative teamwork may facilitates recovery-oriented care and helps to improve team cohesion. Trial registration: Each trial was registered before participant enrolment in the clinicaltrials.gov database: Croatia, Zagreb (Trial Reg. No. NCT03862209); Montenegro, Kotor (Trial Reg. No. NCT03837340); Romania, Suceava (Trial Reg. No. NCT03884933); Macedonia, Skopje (Trial Reg. No. NCT03892473); Bulgaria, Sofia (Trial Reg. No. NCT03922425) Psychiatry Community mental health services Implementation Collaborative Teamwork Role perceptions Background Mental disorders are the main cause for disability worldwide ( 1 ), and contribute substantially to loss of healthy life years ( 2 , 3 ). Moreover, people suffering from mental illnesses are more likely to be excluded from social life, are at higher risk of poverty and stigmatisation ( 2 , 3 ). They are more likely to suffer from medical comorbidity, poor physical health, and are at higher risk of premature death compared to people without mental disorders ( 4 ). Access to and quality of mental healthcare varies considerably across European countries and systems ( 5 ). The World Health Organisation (WHO) reported that in low- and middle-income countries between 76% and 85% of people suffering from mental disorders do not receive the treatment they need ( 1 , 3 ). Many mental health systems have gone through a process of deinstitutionalization by replacing long-stay and institutional care in inpatient settings with community-based alternatives ( 5 , 6 ). Shifting healthcare from the hospitals to community care aims at supporting individuals with mental disorders in maintaining independence, promoting choices, and enhancing inclusion ( 6 ). There are many types of community-based mental health services, with a number of models used conceptualise their organization and the delivery of services. One of the more common types of community-based services is that of a multidisciplinary community mental health team (CMHTs) ( 6 ). CMHTs usually include professions such as nurses, psychiatrists, psychologists, and social workers ( 6 ). The combined expertise and interdisciplinary work practices of these professions enables a client to receive more holistic care addressing their medical, mental and social needs ( 6 ). A frequently used care model for community based care which is recognised as a good practice is the flexible assertive community treatment (FACT) model ( 7 ). The FACT model helps clients receive intensive support within their community by a team using a team case-load and assertive community treatment principles ( 7 ). A case manager coordinates individual case-loads, although all professionals within the team provide mental healthcare. In times of an increased need for treatment and care, the team works together to meet those needs. This care model provides an opportunity for a transition between high- and low-intensity treatment and care and a shared case-load, and thus may enhances recovery ( 7 ). Although recovery from severe mental illness is an individual journey, professional care and guidance can support recovery outcomes ( 8 , 9 ). A recovery-oriented approach focuses on the person, addresses stigmatisation and facilitates social inclusion, and improves quality of life, citizenship, and participation in society ( 3 , 10 ). It is a collaborative process between mental healthcare providers and clients which facilitates shared-decision making and puts the individual recovery version of the clients in the centre of the treatment ( 11 , 12 ). Recovery-oriented practice includes patient empowerment, peer support, the right to informed choice, respecting individual needs, and the right to be treated ethically ( 12 ). Recovery usually occurs in an individual’s personal environment and includes feelings like hope, understanding of competences and skills, having an active and social life, personal autonomy, and living a meaningful life with a positive sense of self ( 10 , 13 ). Peer support in mental health is defined as aid for a person with severe mental illness (SMI) by people with personal experiences of a mental health issues ( 14 ). They can be a member of a mental health team and have been increasingly implemented internationally. The support of peer works can have an positive impact the recovery of people with SMI ( 14 ). If the process of recovery is managed by a highly qualified CMHT supporting discharge from hospital to community, participation in social life and overall patient satisfaction increases ( 15 – 17 ). This requires commitment by each team member, a shared vision, a clear distribution of roles, and a common purpose ( 18 ). Multidisciplinary team functioning is complex and requires a deeper understanding of the different professions operating in teams, such as in CMHTs. Boundaries between the profession can act as barrier and influence communication and coordination negatively which has an impact on patient safety and care integration ( 19 ). Previous research shows that not all healthcare providers work effectively in a multidisciplinary team ( 18 ). Unclear role allocation, lack of clarity regarding leadership can also hinder team functioning ( 18 ). Research has shown that comprehensive community-based mental health services lead to an improvement in healthcare and patient outcomes, including quality of life, treatment adherence, healthcare accessibility, and social outcomes ( 6 , 20 – 22 ). Additionally, CMHTs reduce the number of days spent in hospital, increase patient satisfaction, reduce suicide rates, and number of admissions to the hospital ( 6 , 18 ). Furthermore, most people with SMI favour recovery-oriented healthcare services provided in their community in order to participate in social life and sustain employment ( 13 , 15 , 16 ). These insights have led to the design and implementation of CMHTs for providing inclusive mental healthcare based on the recovery-oriented approach and social support in five sites in five Central and Eastern European countries within the Large-scale implementation of community-based mental health care for people with severe and enduring mental ill health in Europe project (RECOVER-E) ( 23 ). The ultimate aim of the RECOVER-E project is to implement and evaluate multidisciplinary CMHTs delivering care in a recovery-oriented way to people with SMI and compare it to the treatment as usual on three levels: 1) patients outcome, 2) team members; and 3) socioeconomic evaluation ( 23 ). The present study aimed to assess to what extent members of the five CMHTs in five sites had introduced aspects of the recovery-oriented approach after they received a one-week training on the recovery-oriented approach to care for people with SMI in community settings aimed to support the organisation of the their local CMHTs. The secondary aim was to evaluate what the team members’ perceptions on their collaborative care roles and their level of confidence with this role, according to their background profession. Methods And Design Study Design The research presented in this manuscript is part of the RECOVER-E project, a European research project with five patient-randomized trials on the implementation of community-based mental healthcare for people SMI (23). In each of the five sites, the study was designed as a clinical and health-economic evaluation on the basis of a hybrid effectiveness-implementation trial, which assesses both implementation outcomes and patient health outcomes. Each of the five hybrid trials is conducted as pragmatic randomised trial in two parallel groups with measurements among service users and healthcare providers (members of the CMHTs within each site). The present study reports the findings from a paper-based survey among all team members of the CMHTs in each project site at local start of the study, after having completed a one-week training session on the concept of CMHT and the principles of the recovery-oriented practice approach. The local research teams were responsible to distribute the survey to the CMHT members after the training. Study setting Community mental health teams were established and implemented in Croatia, Zagreb; Montenegro, Kotor; Romania, Siret; North Macedonia, Skopje; and Bulgaria, Sofia (Table 1). The full rationale and selection criteria for these sites is described in a prior publication (23). Table 1 : Characteristics of the study settings/project sites Participants Healthcare providers were eligible for joining the CMHT and then participating in the study if they were over the age of 18 working with people with SMI in the five project sites. Additionally, peer workers (persons with lived experience of a SMI). over the age of 18 were asked to join the CMHT and to participated in this study. Each team had to consist of at least one nurse, psychiatrist, psychologist, social worker, and a peer worker. Healthcare professional and peer worker were excluded if they did not meet the inclusion criteria, did not give consent to participate in this study, or were not able to give consent to participate. Each team member of each project site participated on a voluntary basis and gave consent prior to the start of the study. Sampling and recruitment were organised by the local research team in each project site individually. Sampling and recruitment Zagreb, Croatia During a daily meeting at the department of psychiatry at the University Hospital Centre Zagreb (ZUHC) the RECOVER-E project and its goals were presented. Healthcare professionals who were interested in this topic could approach the local principal investigator and decide if they want to participate. All healthcare professionals who accepted to become a part of the CMHT participated in this study, and were employees of the ZUHC. Peer workers were recruited from patients that were treated at the ZUHC due to SMI and were recovered during psychosocial treatment afterwards. Kotor, Montenegro In Montenegro CMHT members were employed by the Special Psychiatric Hospital in Kotor. They have been selected by the director of the clinic based on their commitment to work, their previous work results and on their own motivation and interest to work in this kind of programme and their awareness of the need to provide more than just hospital-based services for service users. The directors explained the project and the nature of the study and asked if they want to participate on a voluntary basis. In early October 2018 three peer worker were recruited from a group of locally treated clients at the hospital and the Mental Health Centre in Kotor. Inclusion criteria were a presence of severe mental health disorder, the willingness to participate in working activities of mental health team, and the capacity to offer peer support based on the opinion of the treating psychiatrist. All healthcare proffesionals and peer workers who accepted to become a part of the CMHT participated in this study. Siret, Romania In Romania CMHT members were selected out of the people working at the hospital in Siret by the local principle investigator. All team members were willing to spend some of their free time on pioneering a new service in mental health. Moreover, they were the most active during the on-site training provided by the project coordination. The peer worker was selected together by the social worker, psychiatrist and psychologist based on their professional experience. All healthcare professionals and the peer worker who accepted to become a part of the CMHT participated in this study. Skopje, North Macedonia All CMHT members were employed at the University Clinic of Psychiatry Skopje and were recruited by the directors of the clinic. They selected the employees based on their willingness and motivation to try something new. The directors explained the project and the nature of the study and asked if they want to participate. The two peer workers, who were recruited, were treated at the clinic due to SMI previously and were recovered during psychosocial treatment. They are not employed at the clinic but were also selected by the directors of the clinic. Everybody took part in the first training that was organized in Skopje. All healthcare professionals and the peer worker who accepted to become a part of the CMHT also decided to participated in this study. Six members went to the second training in the Netherlands and updated the others. Sofia, Bulgaria Healthcare providers were recruited by the director of the MHC Shipkovenski. They decided on a voluntary basis if they want to participate in this project. All CMHT members were employed at the MHC “Prof. N. Shipkovenski” a hospital for the district Sofia. The psychiatrists who work at the MHC Shipkovenski and those who collaborate with the centre suggested patients who were interested to fill in the role as peer workers. The director of the MHC Shipkovenski selected ten potential participants which participated in the training in July 2019. Three of them were invited and agreed to participate in the project. All healthcare professionals and the peer worker who accepted to become a part of the CMHT also decided to participated in this study. Training on recovery-oriented practices After members of the CMHTs were appointed by each mental health service in the five sites, CMHT members participated in a two-week training programme, with one week of the training carried out in their home country and one week as an intensive site visit and training week in the Netherlands, hosted by GGZ Noord-Holland-Noord. In this training, healthcare professionals had the chance to improve their understanding of community based mental health approaches, with the aim of being able to implement a cohesive team in their city or district. The training programme for the CMHT were developed by a multidisciplinary Expert Panel (including a peer worker) and reviewed closely by the implementation site coordinators for local relevance and adaptation. The training covered key components of community mental health care, working with a shared caseload, and home treatments. It focused on building the hands-on skills and competencies necessary for delivering high quality community care, as well as working with peer specialists and families. A substantial component of the training (and subsequent mentoring and hands-on coaching) focused on the most difficult change process in building a sustainable CMHT, which is changing the mindset from viewing treatment for people with SMI as custodial (protection from communities/societies, care in institutions and hospitals) and shift to perceiving services as an aid to a meaningful life in the community. Data collection Data was collected using a paper-based survey administered among CMHT members at the local start of the study during a staff meeting in each site by the local research team after the first week of training in their home country (Table 2). The questionnaire items had been translated prior to the start of the study at each site into the local language by members of the local research team who were fluent in English and in the local language and back translated. It took the team members approximately 15 to 20 minutes to complete the questionnaire. An informed consent was signed by all selected staff members prior to the start of the study. Table 2 : Period of data collection and dates of the two training weeks per project site Measurements Sociodemographic data questionnaire The sociodemographic part of the questionnaire included questions such as year of birth, sex, profession, years of professional experience, and place of work. Recovery Self-Assessment (RSA-Provider Version) The Recovery Self-Assessment (RSA) is a 32-item measure developed to assess to what degree a program implements recovery-oriented practice (24). It is a self-reflective tool that is designed to identify efforts made by healthcare agencies to provided recovery-oriented care. Research has shown that the RSA has moderate to strong internal reliability (Cronbach’s α 0.63 – 0.90) (24-27). Response options include a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and two additional answering options (Don’t know and Not Applicable) (28). There are four different versions of the RSA: Person in recovery, Family member/advocate, provider, and CEOs/Directors. In this study the provider version (RSA-P) was used. The measure covers the following five subscales: Life Goals, Involvement, Diversity of Treatment Options, Choice, and Individually Tailored Services. The Life Goal domain refers to the extent to which staff helps with the development and achievement of life goals based on the preferences of the patient. Involvement indicates to what degree healthcare provider and clients perceive that clients are involved in their healthcare and in decision-making. Diversity of Treatment Option Subscale refers to what extend the healthcare organisation provides different treatment options and supports clients to get involved in non-mental health activities. The Choice domain indicates to what degree healthcare provider and clients feel that choices are available to clients and if the choice is respected. The subscale Individually Tailored Services refers to the perception that healthcare services are tailored to individuals’ personal needs, culture and affectations (27). Higher scores indicate a greater degree of implementation of recovery-oriented practices (24). Team Member Self-Assessment The Team member Self-Assessment Tool (TMSA) developed by the Advancing Integrated Mental Health Solutions (AIMS) Centre of the University of Washington, Psychiatry & Behavioural Sciences Division of Population Health and is a part of the Team building and workflow guide (29). The tool (worksheet) consists of 26-items that allow each member of a care team to think about what collaborative care roles he/she currently practices. The worksheet includes five different care roles: Identify and Engage Patients, Track Treatment Outcome, Initiate, and Provide Treatment, Proactively Adjust Treatment if Patients are not responding, and other tasks Important for our Program. Response options for the first question “ Is this your role ” include yes or no. Answering option for the second question “ Your level of comfort with this task ” include high or medium/low. Data analysis All questionnaires were included in the analysis. Prior to analysis, all variables were checked for data entry errors and missing values. The two response options (‘Don’t Know’ and ‘Not Applicable’) were set as user missing value when conducting the first analysis since this is a common method for categorial variables with response options like ‘Not Applicable’ or ‘Don’t Know’. Then the standard technique to calculate scale scores for each subscale of the RSA-P was used (30). This meant that, for each subscale all associate items were summarized and aggregate measures were constructed for further analysis for the whole sample as well as per project site. This method only allows for a few missing values. Thus, items with a high number (n > 6) of ‘Not Applicable’ responses were reviewed and discussed with the local research teams of each site to understand in what way this response option was interpreted by the CMHT members who completed the questionnaire. Most of these items turned out to be relating to services/treatment options which were not offered by the hospitals, the mental health institutes or not within the scope of the RECOVER-E project. Thus, the answering option ‘Not Applicable’ was combined with ‘Strongly Disagree’ in the second and final analysis, as both indicated that those services were not provided. Bivariate linear regression analyses were applied to explore the impact of predictors on the five aggregate measures for the whole sample. Predictors with significant effects were included in multiple regression models, albeit these were considered as highly tentative given the small sample size. The internal consistency of the RSA-P and its five subscales were evaluated using Cronbach’s alpha coefficient. Descriptive statistics were used to calculate the means and standard deviations for continuous variables and frequencies and percentages for categorical variables for the TMSA tool and demographic data. For interpretation of the findings the cut-off points for the TMSA tool for each profession was 50% indicated that half of the given profession felt like a listed role is their responsibility or that half of them felt confident to fulfil these roles. Two participants indicated ‘other’ as profession and were excluded TMSA analysis. Data was analysed with the Statistical Package for Social Science SPSS version 25 (31). Statistical significance was defined as p<0.05. Results Description of the sample All team members from each site filled in the questionnaire (n=66). Table 3 presents the descriptive characteristics of the sample categorised by countries. The largest community mental health team was the Croatian team with 21 (31.8% of the total sample), the smallest team was the Romanian team with 6 (9.1% of the sample) individuals. Of the total study population 65.2% (n=43) were female. The mean age was 40.02 (SD=10.96) years. A third of the participating professionals were nurses (31.8%). A vast majority of the healthcare professionals had more than five years of experience. Table 3 : Description of the study population (n= 66 healthcare professionals and peer worker) per project site Recovery Self-Assessment Provider Version (RSA-P) Overall Recovery Self-Assessment Scale The members of the CMHT in Romania and Bulgarian reported the highest means of the RSA-P subscales, with an overall scale 4.46 (SD 0.327) and 4.46 (SD 0.211), respectively. The team members of the Croatian team reported an overall mean of 4.16 (SD 0.404). The lowest means were indicated by the Macedonian team 4.05 (SD 0.694) and the Montenegrin team 3.58 (SD 0.275). This pattern was similar for the different subscales (Table 4). Table 4 : Recovery Self-Assessment Scale (Provider Version) per project site Associations between individual characteristics and Recovery Self-Assessment Profession (p=0.029, beta coefficient= 0.271) and professional experience (p=0.008, beta coefficient= -0.328) were associated with the total RSA-P score. However, only professional experience (p=0.036, beta coefficient= -0.268) remained significant in the multiple regression analysis with both predictors. The effect of professional experience on the total RSA-P implied that healthcare providers with fewer years of professional experience were more likely to perceive that their healthcare practice operated recovery-oriented compared to team members with more years of professional experience. RSA-P-Subscales: The amount of professional experience had an impact on the degree to what healthcare provider perceived choices are available to clients and if these choices are respected (p=0.027, beta coefficient= -0.286). More specifically, professionals with fewer years of professional experience were more likely to perceive that individual choices are available to clients and that these choices are respected than with team members with more years of work experience. Additionally, work experience (p=0.003, beta coefficient= -0.357) and profession (p=0.012, beta coefficient= 0.311) were associated with the extent to which staff helps with the development and achievement of life goals based on the preferences of the patients. In the multiple regression analysis with both predictors, only professional experience remained significant (p=0.023, beta coefficient= -0.286,). Thus, CMHT members with more years of professional experience perceived that their role was less supportive regarding helping clients with achieving and developing their individual life goals. Healthcare provider with less years of work experience had a higher tendency to perceive that clients are involved in their healthcare and in decision-making compared to their those with more years of experience (p=0.016, beta coefficient= -0.311). Professionals with more years of work experience felt less like their healthcare organisation provides different treatment options or supports clients to get involved in non-mental health activities (p=0.017, beta coefficient= -0.302). The expected effect of professional experience on the subscale Individually Tailored Services was not significant although close (p=0.051, beta coefficient= -0.251). Team Member Self-Assessment The findings of the TMSA are reported by professions. More than 50% indicate that a majority of members of a profession saw themselves in a certain role and/or felt highly confident in fulfilling these roles. The questionnaire was completed after the healthcare professionals received the first week of training, and started to work as CMHTs. Thus, it is to expected they evaluated their role and responsibilities within the team. Nurses: A large majority of the nurses (n=81.0%) saw themselves in the role of identifying and engaging patients. Nevertheless, only a small number (n=33.3%) stated that they feel highly confident to fulfil the different responsibilities within this role on the CMHT. A third stated that diagnosing behavioural health disorders is their responsibility (n= 33.3%). Over 50% also saw themselves as having a role in tracking treatment outcomes, although only a few felt confident to fulfil this role. A vast majority of nurses saw their role in different responsibilities within this role as well, such as by conducting behavioural health assessments, developing and updating behavioural health treatment plans, educating patient about symptoms and treatment option, brief counselling, activity scheduling, behavioural activation, facilitating referral to specialty care or social services, and creating and supporting relapse prevention plan. However, only a few felt confident to fulfil these responsibilities. A large majority of nurses also stated that proactively adjust treatment if patients are not responding is their role, however less than a third of them felt confident to fulfil these roles. Although other tasks like e.g. administrative support for program (scheduling, resources) is a role more than 50% of the nurses also saw themselves in, only a few felt confident to fulfil these roles (Table 5 – 7). Psychiatrists : The large majority of psychiatrists saw themselves in all listed roles, and also felt confident to fulfil these roles. They particularly identified with the role of tracking treatment outcomes and initiating and providing treatment (Table 5 – 7). Psychologists: A vast majority of psychologists identified with all roles listed and felt highly confident to fulfil these roles. Although they felt like they were responsible for some tasks such as prescribing psychotropic medications, patient education about medications and side effects, identifying and treating coexisting medical conditions, and facilitating referral to specialty care or social services of within the role of tracking treatment outcomes, they saw themselves more in the roles of identifying and engaging patients and initiating and providing treatment (Table 5 – 7). Social workers: A majority of social workers saw themselves in all roles listed, but did not feel confident to fulfil these roles. All social workers stated that they were responsible for identifying people who may need help, engaging patients and introducing the care team to the patient. Interestingly, all social workers saw themselves in the role of tracking outcome of referrals and other treatments, but only two felt confident to fulfil this role (n=25.0%). Initiate and provide treatment is a role mainly psychiatrists identified with; however, all social workers stated that they saw themselves in facilitate referral to specialty care or social services and create and support relapse prevention plans, and indicated feeling highly confident to fulfil these tasks (Table 5 – 7). Peer workers: Almost all peer workers saw themselves in the role of engaging patients in the care program and introduce care team to the patient (n=78.6%), only around a third felt confident to fulfil this role (n=28.6%). Interestingly, more than half of peer workers saw themselves in the role of tracking treatment outcomes, except for tracking patients’ symptoms with measurement tools, although they did not feel confident to fulfil this role. They also stated to be responsible for some tasks within the role of initiating and providing treatment like performing behavioural health assessment, develop and update behavioural health treatment plan, patient education about symptoms and treatment option, and brief counselling, activity scheduling, behavioural activation. However, they only felt confident to fulfil the task of educating patients about symptoms and treatment options. Less than 50% felt responsible for the role of proactively adjusting treatment if patients are not responding. Half of the peer workers identified with the role of fulfilling other tasks important for the program, nevertheless only a few felt confident enough to fulfil this role (Table 5 – 7). Table 5: Team Member Self-Assessment tool: Identify and Engage Patients and Track Treatment Outcome Table 6: Team Member Self-Assessment tool: Initiate and provide treatment Table 7: Team Member Self-Assessment tool: Proactively adjust treatment if patients are not responding and other tasks important for our project Discussion The overall aim of this study was to explore to what degree members of the five CMHTs had introduced aspects of the recovery-oriented practice in community settings after they received the first week of a two-weeks of training session covering the concept of recovery-oriented practice and started to work as CMHT. The secondary aim was to evaluate what the team members think about what collaborative care roles they currently practice within the CMHT, how confident they feel with this role, and to explore differences between the professions involved. In general, we found out that all CMHTs had the perception that they provide recovery-oriented practices to a moderately high degree base on the findings of the RSA-P. Nevertheless, specific aspects such as connecting clients with self-help, peer support or advocacy groups and programs, and encouraging them to attend advisory boards and management meetings showed room for enhanced implementation. Healthcare professionals with less professional experience had the tendency to perceive that their healthcare practice implemented recovery-oriented practice compared to team members with a higher degree of professional experience. Nurses saw themselves mainly in the role of identifying and engaging patients, tracking treatment outcomes, proactively adjusting treatment if patients are not responding and other tasks important for this project. Nevertheless, compared to the psychiatrists and psychologists, most of the nurses did not feel confident to fulfil specific roles. Psychiatrists, psychologists, and social workers saw themselves in almost all roles listed. In comparison with the psychologists and social workers, psychiatrists felt highly confident to fulfil each role. Peer workers mainly saw themselves in the role of engaging patients and fulfil other tasks important to the project. Nevertheless, they did not feel confident to fulfil specific roles. Interestingly, a majority of peer workers saw themselves in roles included within the domain of track treatment outcomes and initiate and provide treatment. In 2013, the WHO released the Mental Health Action Plan (32) stating the need for availability of recovery-oriented mental health services in the community. In our study, all CMHTs had already introduced various aspects of recovery-oriented practices. However, it needs to be considered that most team members were highly enthusiastic about community care prior to the start of the project which might had a positive impact on the results. This findings are consistent with those by Simmonds et al. (22), they reported that a high level of enthusiasm for community care has been seen by all members of CMHTs which have been evaluated. Nevertheless, it cannot be concluded that enthusiasm and motivation alone have an impact on the quality of care provided by healthcare professionals. Additionally, members of each CMHTs of this study have been selected by the research team based on their commitment or were motivated to be part of this project. Thus, it is possible that the motivation to provide recovery-oriented care within the teams is higher compared to healthcare providers who have not been selected or are not interested in community care. These findings are consistent with those by Malone et al. (6). They conducted a systematic review on the effects of CMHT management compared to non-research CMHT management. All healthcare professional working as CMHT included in their review have been selected or linked to the research programme. Hence, it is not clear if the results can be generalised from selected or highly committed professionals to non-selected professionals. The same applies to the findings of this study. The members of each CMHT of this study attended the first week of two-weeks training on the concept of recovery provided by the coordinating project team. This training might have a positive impact on the perceptions of the healthcare provider regarding degree of recovery-oriented care within their organisation. These findings agree with those of Hornik-Lurie et al. (12). In their study they found out that staff which had been trained in recovery-oriented interventions had higher perceptions of recovery-oriented care compared to nontrained staff (12). Thus, training on recovery-oriented practices may be an effective strategy to facilitate implementation of this care approach. In this study, higher RSA-P scores and thus the tendency to perceive that more aspects of recovery-oriented practice were introduced were detected in healthcare professionals with limited professional experience. Since the Substance Abuse and Mental Health Services Administration (SAMHSA) of the US incorporated a curriculum on recovery-oriented care into the training of mental health professionals in 2009, the recovery-oriented approach has become more conversant (33). Thus, it is possible that the younger generation is more trained in the principles of the recovery-oriented approach due to changes to the curriculum over the last years (33). CMHT members of this study, especially nurses and peer workers, are not always aware of their role or responsibilities or do not feel confident to fulfil specific roles. It makes sense that for example nurses do not feel confident doing some of the tasks that a psychiatrist usually does, as it is not necessarily their role in the teams, it may be something that they have not been trained for and/or it is something that they are legally not allowed to. Moreover, it may be due to the specific training/education these professionals acquire through their university career as well as longstanding traditions. In Croatia for example university level education of nurses is very new (34). Thus, nurses may have not yet acquired their professional identity. This might have an impact on how nurses identified with certain roles and responsibilities. Additionally, peer workers, in general, do not have any specific peer support education to define their professional identity. This findings are consistent with those by Carpenter et al. (35); in their study they investigated the impact of working in multidisciplinary CMHTs in North England on social workers and health professionals. They particularly examined the relationship between team identification, team functioning, psychological well-being and job satisfaction (35). Although they found out that there is a moderate to high level of role clarity within the members of CMHTs, various role conflicts were detected (35). Conflicts included disagreements between professions or discipline, workload, misunderstandings of roles and responsibilities or an increase in paperwork (35). Carpenter et al. (35) concluded that role clarity promoted job satisfaction and decreases work related stress. In our study role clarity seems to be problematic, thus conflicts and disagreements may be pre-programmed. In addition, psychiatrists, psychologist, and social workers saw themselves in almost all listed roles, regardless of being confident to fulfil those roles, an unclear division of roles impeded effective team collaboration and cooperation. The existing stigmatisation in the society and among healthcare professionals may had an impact on the role of peer workers. The fact that peer workers are more and more involved in providing mental health care requires a huge shift in the way mental health professionals think. Additionally, the level of self-stigmatisation among peers may be very high and influencing these results of this study as well (36). Another source of role conflict detected by Carpenter et al. (35) was inadequate allocation of resources for people with SMI e.g. access to appropriate service based on individual needs. These findings agree with those by Singh (18), in his study he reported that the rapid reduction of beds for people with SMI had an negative impact on the care provided by CMHTs. Although CMHTs may operate effectively, a majority of patients with SMI need to be admitted to acute hospital care to receive the care they need (18). Thus, access to an adequate number of acute beds and hospital care is necessary not only for patients with SMI but also for CMHTs to provide effective community-based mental health care and to avoid conflicts. Implications for practice and policy It is important that CMHTs consist of healthcare professionals with a wide range of professional experience and different competences to ensure high quality of community-based mental health services. Role clarity, particularly the role of nurses and peer workers, is important to run CMHTs effectively and to avoid conflicts within the teams. More training and different steps for ensuring team cohesion may be necessary. Strengths and Limitations The study had a high participation rate and used some validated measures. However, this is a descriptive study in five mental health centres in different Eastern and Central Europe countries, hence the generalizability of the findings is uncertain. Moreover, all healthcare providers of all five CMHT volunteered to be part of a mobile team, so their personal commitment and their own motivation might influence the results positively compared to healthcare provider who are not involved in such a project. In addition, results may be driven by particular countries due to the difference in sample size. Due to relatively small sample sizes per country, country-specific analysis cannot be performed. Conclusion Trainings on community-based practices and collaborative teamwork may enhance recovery-oriented practice and helps to allocate roles and responsibilities clearly. Recovery-oriented care is a complex concept which requires time, skills and professional mindset to shift different care approaches to this new way of working. Thus, investments are needed to support CMHT members to gradually shift towards seeing strengths and weaknesses of providing community-based recovery-oriented care and being a part of the recovery process of patients rather than being leading role of this process. Furthermore, roles and responsibilities within the CMHT should be clear to everyone, particularly the role of peer workers. Additional training is needed support the role of peer workers within the CMHT and enhance their self-esteem. Abbreviations WHO: World Health Organisation SMI: Severe Mental Illness CMHT: Community Mental Health Team RECOVER-E: Large-scale implementation of community-based mental health care for people with severe and enduring mental ill health in Europe RSA-P: Recovery self-assessment tool Provider Version TMSA: Team Member Self-Assessment Tool Declarations Ethics approval Ethics approval was obtained of the Medical Ethics Committee of the Medical Faculty Heidelberg (S-496/2018) prior to the start of the study in August 2018 by the Heidelberg Team. Additionally, each study in each implementation site has received ethical approval from a local institutional review board prior to the start of the study: Name of the committee for Zagreb, Croatia: Ethics Committee of the University Hospital Centre (UHC) Zagreb; Ethical approval: 18.07.2018, Number: 02/21 AG, Class 8.1-18/149-2 Name of the committee for Kotor, Montenegro: Ethics Committee of the HI Specialized Psychiatric Hospital Dobrota Kotor, Ethical approval: 28.09.2018, Number 3463/1 Name of the committee for Suceava, Romania: Ethics Council Chronic Psychiatric Hospital Siret, Ethical approval: 21.11.2018 Name of the committee for Skopje, North Macedonia: Ethical Committee for Research on Human Subjects, Medical Faculty, SS Cyril and Methodius University Skopje, Skopje, North Macedonia; Ethical approval: 21.05.2018 Name of the committee for Sofia, Bulgaria: Commission of Ethics at the National Centre of Public Health and Analyses, Sofia, Bulgaria; Ethical approval: 25.01.2019. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Consent to participate Written informed consent was obtained from all participants before enrolment. Consent for publication Not applicable Availability of data and material The dataset generated and analysed during the current study will not be made publicly available due to European Data Protection Law but maybe available by the corresponding author on reasonable request. Competing interests The authors declare that they have no conflict of interest. Funding This project has received funding from the European Union’s Horizon 2020 research and innovation programme under Grant Agreement 779362. Authors’ contributions MW and LSZ conceived this study and elaborated the research protocol. CR wrote the manuscript. All authors provided substantial comments and approved the final version of the manuscript. Acknowledgements We would like to thank all healthcare professionals who participated in this study and contribute to the improvement of mental health care. Moreover, would we like to acknowledges the mandate and funding for this project from the European Union’s Horizon 2020 Research and Innovation Programme and the Global Alliance for Chronic Disease. Authors’ information Not applicable References Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. The Lancet. 2007;370(9590):841-50. Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015;386(9995):743-800. 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Tables Table 1: Characteristics of the study settings/project sites Zagreb, Croatia Kotor, Montenegro Siret, Romania Skopje, Macedonia Sofia, Bulgaria Catchment area (inhabitants) 980.000 89.000 (initially/at beginning of the study) 165.000 enlarged from October 2019** 100.000 500.000 1.300.000**** Total number of psychiatric patients in catchment area 12.226 9.000 (initially / at the beginning of thy study)16.000 *enlarged / from October 2019*** 51.000 30.000* 27.000***** CMHT staff structure Psychiatrists, Psychologist, Nurses, Social Worker,Non-mental health Professionals Psychiatrists, Psychologist, Nurses Social Worker Psychiatrists, Psychologist, Nurses, Social Worker, Occupational therapists Psychiatrists, Psychologist, Nurses, Social Worker, Psychiatric Trainees, Occupational Therapists, Disability Therapists Psychiatrists, Psychologist, Nurses, Social Worker Type of services for people with mental health issues Inpatient treatment (acute and chronic care) Psychotherapeutic inpatient care,Outpatient visits 1 per months and daily hospital for first episode psychosis and schizophreniaMobile team since 2017 Inpatient and outpatient treatment (acute and chronic care) Community based mental health service since 2010 Inpatient and outpatient treatment (acute and chronic care) Inpatient and outpatient treatment (acute and chronic care) Inpatient and outpatient treatment (acute and chronic care) Financing of mental health services Croatian Health Insurance Fund Out-of-pocket costs are not significant National Health Insurance Fund (Bismarck’s model of financing) Funds from donations Romanian Health Insurance Fund through the DRG system Macedonian Health Insurance Fund State financing Municipality National Health Insurance Fund and Out-of-pocket * Clinic of Psychiatry, Psychiatric hospital Skopje and outpatients MH Services ** Census of Population in Montenegro 2011 / http://www.monstat.org/userfiles/file/popis2011/saopstenje/saopstenje(1).pdf *** Data gathered from hospital and mental health centres in each municipality (free estimation / there is no published source) **** https://www.nsi.bg/en/content/6704/population-districts-municipalities-place-residence-and-sex *****Data form NCPHA database (not published) Table 2: Period of data collection and dates of the two training weeks per project site Zagreb, Croatia Kotor, Montenegro Siret, Romania Skopje, North Macedonia Sofia, Bulgaria Period of Recruitment May 2018 – September 2018 1. – 15. October 2018 January 2018 and March 2018 20. – 31. May 2019 April 2019 – June 2019 Training Week 1 (on-site-training) 24. – 28. September 2018 4. – 8. November 2018 28. January – 02. February 2019 24. – 28. June 2019 15. – 19. July 2019 Data collection February 2019 February 2019 April 2019 June 2019 November 2019 Training Week 2 (Netherlands) 6. – 10. May 2019 6. – 10. May 2019 6. – 10. May 2019 02. – 06. December 2019 02. – 06. December 2019 Table 3: Description of the study population (n= 66 healthcare professionals and peer worker) per project site Project site Zagreb, Croatia n= 21 Kotor, Montenegro n=15 Siret, Romania n= 6 Skopje, North Macedonia n=10 Sofia, Bulgaria n=14 Total N=66 Gender Female Male 15 (71.4%) 6 (28.6%) 9 (60.0%) 6 (40.0%) 4 (66.7%) 2 (33.3%) 5 (50.0%) 5 (50.0%) 10 (71.4%) 4 (28,6%) 43 (65.2%) 23 (34.8%) Age Mean (SD) 41.3 (12.56) 38.47 (9.71) 43.67 (6.98) 39.10 (11.22) 38.93 (11.83) 40.02 (10.96) Profession Nurse Psychiatrist Psychologist Social worker Peer worker Other 9 (42.9%) 4 (19.0%) 1 (4.8%) 3 (14.3%) 4 (19.0%) 0 5 (33.3%) 4 (26.7%) 2 (13.3%) 1 (6.7%) 3 (20.0%) 0 2 (33.3%) 1 (16.7%) 1 (16.7%) 1 (16.7%) 1 (16.7%) 0 (16.7%) 2 (20.0%) 2 (20.0%) 2 (20.0%) 1 (10.0%) 2 (20.0%) 1 (10.0%) 3 (21.4%) 2 (14.3%) 3 (21.4%) 2 (14.3%) 4 (28.6%) 0 21 (31.8%) 13 (19.7%) 9 (13.6%) 8 (12.1%) 14 (21.2%) 1 (1.5%) Professional Experience Less than one year Between one and two years Between two and three years Between three and four years Between four and five years More than five years 0 1 (4.8%) 3 (14.3%) 2 (9.5%) 1 (4.8%) 14 (66.7%) 2 (13.3%) 0 0 0 0 13 (86.7%) 1 (16.7%) 0 0 1 (16.7%) 0 4 (66.7%) 1 (10.0%) 1 (10.0%) 0 1 (10.0%) 3 (30.0%) 4 (40.0%) 4 (28.6%) 3 (21.4%) 0 0 0 7 (50.0%) 8 (12.1%) 5 (7.6%) 3 (4.5%) 4 (6.1%) 4 (6.1%) 42 (63.6%) *Team size varies due different local human resources Table 4: Recovery Self-Assessment Scale (Provider Version) per project site Project sites RSA-P subscale, mean (standard deviation) Zagreb, Croatia Kotor, Montenegro Siret, Romania Skopje, Macedonia Sofia, Bulgaria Life Goals 4.09 (0.456) 3.74 (0.327) 4.64 (0.368) 4.02 (0.684) 4.38 (0.281) Involvement 3.84 (0.568) 2.67 (0.645) 4.63 (0.446) 3.95 (0.880) 4.57 (0.312) Diversity of treatment option 4.17 (0.536) 3.07 (0.230) 4.60 (0.357) 4.05 (0.754) 4.70 (0.188) Choice 4.44 (0.433) 4.53 (0.317) 4.48 (0.349) 4.02 (0.722) 4.79 (0.146) Individually tailored service 3.99 (0.457) 3.35 (0.470) 4.71 (0.368) 4.06 (0.914) 4.63 (0.235) Total RSA-P 4.16 (0.404) 3.58 (0.275) 4.46 (0.327) 4.05 (0.694) 4.46 (0.211) Table 5: Team Member Self-Assessment tool: Identify and Engage Patients and Track Treatment Outcome In total n=65 professionals Nurse n=21 Psychiatrist n=13 Psychologist n=9 Social worker n=8 Peer worker n=14 Identify and Engage Patients Identify People who may need help Is this my role a 17 (81.0%) 13 (100.0%) 8 (88.9%) 8 (100.0%) 3 (21.4%) Highly confident b 7 (33.3%) 13 (100.0%) 8 (88.9%) 6 (75.0%) 2 (14.2%) Screen for behavioural health problems using valid measures Is this my role a 13 (61.9%) 12 (92.3%) 8 (88.9%) 5 (62.5%) 1 (7.1%) Highly confident b 5 (23.8%) 11 (84.6%) 6 (66.7%) 2 (25.0%) 1 (7.1%) Diagnose behavioural health disorders Is this my role a 7 (33.3%) 13 (100.0%) 7 (77.7%) 5 (62.5%) 1 (7.1%) Highly confident b 5 (23.8%) 12 (92.3%) 6 (66.7%) 1 (12.5%) 0 (0.0%) Engage patients in collaborative care program and introduce care team Is this my role a 17 (81.0%) 13 (100.0%) 7 (77.7%) 8 (100.0%) 11 (78.6%) Highly confident b 10 (47.6%) 10 (76.9%) 4 (44.4%) 4 (50.0%) 4 (28.6%) Track Treatment Outcome Track treatment engagement & adherence using registry Is this my role a 15 (71.4%) 12 (92.3%) 5 (55.6%) 5 (62.5%) 8 (57.1%) Highly confident b 3 (14.3%) 9 (69.2%) 1 (11.1%) 2 (25.0%) 1 (7.1%) Reach out to patients who are non-adherent or disengaged Is this my role a 17 (81.0%) 12 (92.3%) 8 (88.9%) 6 (75.0%) 9 (64.3%) Highly confident b 6 (28.6%) 8 (61.5%) 3 (33.3%) 2 (25.0%) 1 (7.7%) Track patients’ symptoms with measurement tool Is this my role a 12 (57.1%) 12 (92.3%) 8 (88.9%) 5 (62.5%) 4 (28.6%) Highly confident b 5 (28.8%) 9 (69.2%) 5 (55.5%) 3 (37.5%) 0 (0.0%) Track medication side effects and concerns Is this my role a 13 (61.9%) 13 (100.0%) 4 (44.4%) 3 (37.5%) 7 (50.0%) Highly confident b 9 (42.9%) 11 (84.6%) 1 (11.1%) 1 (12.5%) 1 (7.1%) Track outcome of referrals and other treatments Is this my role a 15 (71.4%) 13 (100.0%) 7 (77.7%) 8 (100.0%) 8 (57.1%) Highly confident b 8 (38.1%) 11 (84.6%) 4 (44.4%) 2 (25.0%) 2 (14.3%) Absolute Numbers; a Answering categories were: yes; no; b Answering categories were: high; Med/low confident; ‘other n=1’ was excluded from this analysis Table 6: Team Member Self-Assessment tool: Initiate and provide treatment In total n=65 professionals Nurse n=21 Psychiatrist n=13 Psychologist n=9 Social worker n=8 Peer worker n=14 Initiate and provide treatment Perform behavioural health assessment Is this my role a 12 (57.1%) 13 (100.0%) 8 (88.9%) 6 (75.0%) 8 (57.1%) Highly confident b 5 (28.8%) 11 (84.6%) 5 (55.6%) 3 (37.5%) 2 (14.3%) Develop and update behavioural health treatment plan Is this my role a 12 (57.1%) 13 (100.0%) 8 (88.9%) 5 (62.5%) 10 (71.4%) Highly confident b 3 (14.3%) 11 (84.6%) 3 (33.3%) 2 (25.0%) 2 (14.3%) Patient education about symptoms and treatment option Is this my role a 14 (66.7%) 13 (100.0%) 8 (88.9%) 4 (50.0%) 9 (64.3%) Highly confident b 7 (33.3%) 13 (100.0%) 6 (66.7%) 4 (50.0%) 8 (57.1%) Prescribe psychotropic medications Is this my role a 4 (19.0%) 13 (100.0%) 1 (11.1%) 1 (12.5%) 1 (7.1%) Highly confident b 1 (4.8%) 13 (100.0%) 1 (11.1%) 0 (0.0%) 0 (0.0%) Patient education about medications and side effects Is this my role a 6 (28.6%) 13(100.0%) 2 (22.2%) 1 (12.5%) 4 (28.6%) Highly confident b 4 (19.0%) 13 (100.0%) 2 (22.2%) 0 (0.0%) 1 (7.1%) Brief counselling, activity scheduling, behavioural activation Is this my role a 13 (61.9%) 13 (100.0%) 9 (100.0%) 7 (87.5%) 8 (57.1%) Highly confident b 7 (33.3%) 11 (84.6%) 6 (66.7%) 5 (62.5%) 2 (14.3%) Evidence-based psychotherapy Is this my role a 6 (28.6%) 11 (84.6%) 8 (88.9%) 3 (37.5%) 1 (7.1%) Highly confident b 4 (21.1%) 8 (61.5%) 6 (66.7%) 1 (12.5%) 0 (0.0%) Identify and treat coexisting medical conditions Is this my role a 7 (33.3%) 13 (100.0%) 3 (33.3%) 1 (12.5%) 0 (0.0%) Highly confident b 4 (21.1%) 11 (84.6%) 3 (3339%) 0 (0.0%) 0 (0.0%) Facilitate referral to specialty care or social services Is this my role a 13 (61.9%) 13 (100.0%) 4 (44.4%) 8 (100.0%) 2 (14.3%) Highly confident b 5 (28.8%) 11 (84.6%) 2 (22.2%) 7 (87.5%) 1 (7.1%) Create and support relapse prevention plan Is this my role a 17 (81.0%) 13 (100.0%) 9 (100.0%) 8 (100.0%) 5 (35.7%) Highly confident b 8 (38.1%) 13 (100.0%) 6 (66.7%) 5 (62.5%) 1 (7.1%) Absolute Numbers; a Answering categories were: yes; no; b Answering categories were: high; Med/low confident; ‘other n=1’ was excluded from this analysis Table 7: Team Member Self-Assessment tool: Proactively adjust treatment if patients are not responding and other tasks important for our project In total n=65 professionals Nurse n=21 Psychiatrist n=13 Psychologist n=9 Social worker n=8 Peer worker n=14 Proactively adjust treatment if patients are not responding Assess need for changes in treatment Is this my role a 15 (71.4%) 13 (100.0%) 7 (77.8%) 7 (87.5%) 5 (35.7%) Highly confident b 4 (21.1%) 12 (92.3%) 4 (44.4%) 5 (62.5%) 0 (0.0%) Facilitate changes in treatment/ treatment plan Is this my role a 15 (71.4%) 13 (100.0%) 9 (100.0%) 7 (87.5%) 5 (35.7%) Highly confident b 5 (28.8%) 10 (76.9%) 4 (44.4%) 4 (50.0%) 0 (0.0%) Provide caseload-focused psychiatric consultation Is this my role a 13 (61.9%) 13 (100.0%) 4 (44.4%) 5 (62.5%) 6 (42.9%) Highly confident b 6 (28.6%) 11 (84.6%) 0 (0.0%) 2 (5.0%) 2 (14.3%) Provide in-person psychiatric assessment when needed Is this my role a 12 (57.1%) 13 (100.0%) 4 (44.4%) 1 (12.5%) 1 (7.1%) Highly confident b 5 (23.8%) 13 (100.0%) 0 (0.0%) 1 (12.5%) 1 (7.1%) Other tasks important for this program Coordinate communication among team members/ providers Is this my role a 11 (52.4%) 11 (84.6 %) 8 (88.9%) 5 (62.5%) 7 (50.0%) Highly confident b 4 (21.1%) 9 (69.2%) 5 (55.6%) 3 (37.5%) 3 (21.4%) Administrative support for program (e.g., scheduling, resources) Is this my role a 15 (71.4%) 11 (84.6%) 6 (66.7%) 7 (87.5%) 7 (50.0%) Highly confident b 4 (21.1%) 9 (69.2%) 3 (33.3%) 4 (50.0%) 2 (14.3%) Clinical supervision for Program Is this my role a 10 (47.6%) 12 (92.3%) 5 (55.6%) 4 (50.0%) 7 (50.0%) Highly confident b 5 (23.8%) 12 (92.3%) 3 (33.3%) 1 (12.5%) 3 (21.4%) Absolute Numbers; a Answering categories were: yes; no; b Answering categories were: high; Med/low confident; ‘other n=1’ was excluded from this analysis Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 21 Apr, 2021 Review # 2 received at journal 19 Apr, 2021 Reviewer # 2 agreed at journal 17 Apr, 2021 Review # 1 received at journal 25 Feb, 2021 Editor assigned by journal 06 Feb, 2021 Reviewers invited by journal 06 Feb, 2021 Reviewer # 1 agreed at journal 06 Feb, 2021 Submission checks completed at journal 06 Feb, 2021 Editor invited by journal 03 Feb, 2021 First submitted to journal 19 Dec, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Roth","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-3346-1191","institution":"University Hospital Heidelberg,","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Catharina","middleName":"","lastName":"Roth","suffix":""},{"id":10668834,"identity":"c7fecf2d-9ac3-48d0-b490-32eb5b203855","order_by":1,"name":"Michel 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Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Bjedov","suffix":""},{"id":10668837,"identity":"c48c9307-9548-4e9f-897a-b4f6004d4d1b","order_by":4,"name":"Sara Medved","email":"","orcid":"","institution":"Zagreb University Hospital Centre, Clinic for Pschiatry and Psychological Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Medved","suffix":""},{"id":10668838,"identity":"4dcf17db-8ca5-4112-89ed-dc3c66ee04d6","order_by":5,"name":"Ana Istvanovic","email":"","orcid":"","institution":"Croatian Institute of Public Health, Zagreb Croatia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ana","middleName":"","lastName":"Istvanovic","suffix":""},{"id":10668839,"identity":"3b758d81-d847-43c0-868e-67ee5eb38fd0","order_by":6,"name":"Danijela Stimac Grbic","email":"","orcid":"","institution":"Croatian Institute of Public Health, Zagreb Croatia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Danijela","middleName":"Stimac","lastName":"Grbic","suffix":""},{"id":10668840,"identity":"f617cc3d-05ab-4b36-beab-e6d89e05b3b7","order_by":7,"name":"Ivana Pavic","email":"","orcid":"","institution":"Croatian Institution of Public Health, Zagreb Croatia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ivana","middleName":"","lastName":"Pavic","suffix":""},{"id":10668841,"identity":"599d7c65-27d2-4301-829a-d0f545028e5d","order_by":8,"name":"Aleksander Tomcuk","email":"","orcid":"","institution":"Health Institution Special Psychiatric Hospital Dobrota Kotor","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aleksander","middleName":"","lastName":"Tomcuk","suffix":""},{"id":10668842,"identity":"2340b386-bc45-44b2-86d2-386a6d96b6ff","order_by":9,"name":"Jovo Dedovic","email":"","orcid":"","institution":"Health Institution Special Psychiatric Hospital Dobrota Kotor","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jovo","middleName":"","lastName":"Dedovic","suffix":""},{"id":10668843,"identity":"b5165042-d025-41e8-a853-e9a3efd0bcc4","order_by":10,"name":"Tatijana Djurisic","email":"","orcid":"","institution":"Public Health Institute of Montenegro","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tatijana","middleName":"","lastName":"Djurisic","suffix":""},{"id":10668844,"identity":"859054a7-aaaf-4295-a686-2d8daa0168bc","order_by":11,"name":"Raluca Ileana Nica","email":"","orcid":"","institution":"Institute Liga Romana pentru Sanatate Mintala","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Raluca","middleName":"Ileana","lastName":"Nica","suffix":""},{"id":10668845,"identity":"8291c6fa-5c3a-496b-9109-e7a6be663c43","order_by":12,"name":"Tiberiu Rotaru","email":"","orcid":"","institution":"Siret Psychiatric Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tiberiu","middleName":"","lastName":"Rotaru","suffix":""},{"id":10668846,"identity":"0a2415dd-1aa2-4b47-86db-0ed25104a23d","order_by":13,"name":"Antoni Novotni","email":"","orcid":"","institution":"University Clinic of Psychiatry, UCPS Skopje","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Antoni","middleName":"","lastName":"Novotni","suffix":""},{"id":10668847,"identity":"1bfd39c9-5560-4300-91be-64bacad1c939","order_by":14,"name":"Stojan Bajraktarov","email":"","orcid":"","institution":"University Clinic of Psychiatry, UCPS Skopje","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Stojan","middleName":"","lastName":"Bajraktarov","suffix":""},{"id":10668848,"identity":"86ac7b58-f91f-4ba0-8130-bb51632f276f","order_by":15,"name":"Milos Milutinovic","email":"","orcid":"","institution":"University Clinic of Psychiatry, UCPS Skopje","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Milos","middleName":"","lastName":"Milutinovic","suffix":""},{"id":10668849,"identity":"31672811-629a-43e1-9aeb-b913d89a63d7","order_by":16,"name":"Vladimir Nakov","email":"","orcid":"","institution":"National Centre of Public Health and Analyses, Directorate Mental Health and Prevention of Addictions","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vladimir","middleName":"","lastName":"Nakov","suffix":""},{"id":10668850,"identity":"3f96141b-7c9b-4d72-bcd4-097077626d7f","order_by":17,"name":"Zahari Zarkov","email":"","orcid":"","institution":"National Centre of Public Health and Analyses, Directorate Mental Health and Prevention of Addictions","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zahari","middleName":"","lastName":"Zarkov","suffix":""},{"id":10668851,"identity":"a804680c-76af-4dd5-8135-40772a526c0d","order_by":18,"name":"Roumyana Dinolova","email":"","orcid":"","institution":"National Centre of Public Health and Analyses, Directorate Mental Health and Prevention of Addicitons","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Roumyana","middleName":"","lastName":"Dinolova","suffix":""},{"id":10668852,"identity":"fea42096-25f7-4770-afd7-b15c5d096f37","order_by":19,"name":"Bethany Hipple Walters","email":"","orcid":"","institution":"Dutch Institute for Mental Health and Addiction, Trimbos Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bethany","middleName":"Hipple","lastName":"Walters","suffix":""},{"id":10668853,"identity":"b55e1356-3b0a-4e57-ac19-a23507fae544","order_by":20,"name":"Laura Shields-Zeeman","email":"","orcid":"","institution":"Dutch Institute for Mental Health and Addiction, Trimbos Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Shields-Zeeman","suffix":""},{"id":10668854,"identity":"88ed78d8-4b82-4daa-b7ea-4617fd81cbb3","order_by":21,"name":"Ionela Petrea","email":"","orcid":"","institution":"Dutch Institute for Mental Health and Addiction, Trimbos Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ionela","middleName":"","lastName":"Petrea","suffix":""}],"badges":[],"createdAt":"2021-02-06 23:06:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-215308/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-215308/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13659329,"identity":"1abc2902-1347-4740-84b5-1d023d0fff64","added_by":"auto","created_at":"2021-09-17 10:19:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1019332,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-215308/v1/7f3c7b8d-fd66-4c0b-bd93-f995d1f9843b.pdf"}],"financialInterests":"","formattedTitle":"Recovery-oriented practices and role perceptions of healthcare staff providing community-based mental healthcare as team in Central and Eastern Europe: an observational study","fulltext":[{"header":"Background","content":" \u003cp\u003eMental disorders are the main cause for disability worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), and contribute substantially to loss of healthy life years (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Moreover, people suffering from mental illnesses are more likely to be excluded from social life, are at higher risk of poverty and stigmatisation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). They are more likely to suffer from medical comorbidity, poor physical health, and are at higher risk of premature death compared to people without mental disorders (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Access to and quality of mental healthcare varies considerably across European countries and systems (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The World Health Organisation (WHO) reported that in low- and middle-income countries between 76% and 85% of people suffering from mental disorders do not receive the treatment they need (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMany mental health systems have gone through a process of deinstitutionalization by replacing long-stay and institutional care in inpatient settings with community-based alternatives (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Shifting healthcare from the hospitals to community care aims at supporting individuals with mental disorders in maintaining independence, promoting choices, and enhancing inclusion (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). There are many types of community-based mental health services, with a number of models used conceptualise their organization and the delivery of services. One of the more common types of community-based services is that of a multidisciplinary community mental health team (CMHTs) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). CMHTs usually include professions such as nurses, psychiatrists, psychologists, and social workers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The combined expertise and interdisciplinary work practices of these professions enables a client to receive more holistic care addressing their medical, mental and social needs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). A frequently used care model for community based care which is recognised as a good practice is the \u003cem\u003eflexible assertive community treatment\u003c/em\u003e (FACT) model (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The FACT model helps clients receive intensive support within their community by a team using a team case-load and assertive community treatment principles (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A case manager coordinates individual case-loads, although all professionals within the team provide mental healthcare. In times of an increased need for treatment and care, the team works together to meet those needs. This care model provides an opportunity for a transition between high- and low-intensity treatment and care and a shared case-load, and thus may enhances recovery (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough recovery from severe mental illness is an individual journey, professional care and guidance can support recovery outcomes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A recovery-oriented approach focuses on the person, addresses stigmatisation and facilitates social inclusion, and improves quality of life, citizenship, and participation in society (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). It is a collaborative process between mental healthcare providers and clients which facilitates shared-decision making and puts the individual recovery version of the clients in the centre of the treatment (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Recovery-oriented practice includes patient empowerment, peer support, the right to informed choice, respecting individual needs, and the right to be treated ethically (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Recovery usually occurs in an individual\u0026rsquo;s personal environment and includes feelings like hope, understanding of competences and skills, having an active and social life, personal autonomy, and living a meaningful life with a positive sense of self (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Peer support in mental health is defined as aid for a person with severe mental illness (SMI) by people with personal experiences of a mental health issues (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). They can be a member of a mental health team and have been increasingly implemented internationally. The support of peer works can have an positive impact the recovery of people with SMI (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIf the process of recovery is managed by a highly qualified CMHT supporting discharge from hospital to community, participation in social life and overall patient satisfaction increases (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This requires commitment by each team member, a shared vision, a clear distribution of roles, and a common purpose (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Multidisciplinary team functioning is complex and requires a deeper understanding of the different professions operating in teams, such as in CMHTs. Boundaries between the profession can act as barrier and influence communication and coordination negatively which has an impact on patient safety and care integration (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Previous research shows that not all healthcare providers work effectively in a multidisciplinary team (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Unclear role allocation, lack of clarity regarding leadership can also hinder team functioning (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearch has shown that comprehensive community-based mental health services lead to an improvement in healthcare and patient outcomes, including quality of life, treatment adherence, healthcare accessibility, and social outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Additionally, CMHTs reduce the number of days spent in hospital, increase patient satisfaction, reduce suicide rates, and number of admissions to the hospital (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Furthermore, most people with SMI favour recovery-oriented healthcare services provided in their community in order to participate in social life and sustain employment (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese insights have led to the design and implementation of CMHTs for providing inclusive mental healthcare based on the recovery-oriented approach and social support in five sites in five Central and Eastern European countries within the \u003cem\u003eLarge-scale implementation of community-based mental health care for people with severe and enduring mental ill health in Europe\u003c/em\u003e project (RECOVER-E) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The ultimate aim of the RECOVER-E project is to implement and evaluate multidisciplinary CMHTs delivering care in a recovery-oriented way to people with SMI and compare it to the treatment as usual on three levels: 1) patients outcome, 2) team members; and 3) socioeconomic evaluation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe present study aimed to assess to what extent members of the five CMHTs in five sites had introduced aspects of the recovery-oriented approach after they received a one-week training on the recovery-oriented approach to care for people with SMI in community settings aimed to support the organisation of the their local CMHTs. The secondary aim was to evaluate what the team members\u0026rsquo; perceptions on their collaborative care roles and their level of confidence with this role, according to their background profession.\u003c/p\u003e "},{"header":"Methods And Design","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\n\u003cp\u003eThe research presented in this manuscript is part of the RECOVER-E project, a European research project with five patient-randomized trials on the implementation of community-based mental healthcare for people SMI (23). In each of the five sites, the study was designed as a clinical and health-economic evaluation on the basis of a hybrid effectiveness-implementation trial, which assesses both implementation outcomes and patient health outcomes. Each of the five hybrid trials is conducted as pragmatic randomised trial in two parallel groups with measurements among service users and healthcare providers (members of the CMHTs within each site).\u003c/p\u003e\n\u003cp\u003eThe present study reports the findings from a paper-based survey among all team members of the CMHTs in each project site at local start of the study, after having completed a one-week training session on the concept of CMHT and the principles of the recovery-oriented practice approach. The local research teams were responsible to distribute the survey to the CMHT members after the training.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eStudy setting\u003c/h2\u003e\n\u003cp\u003eCommunity mental health teams were established and implemented in Croatia, Zagreb; Montenegro, Kotor; Romania, Siret; North Macedonia, Skopje; and Bulgaria, Sofia (Table 1). The full rationale and selection criteria for these sites is described in a prior publication (23).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable \u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e: Characteristics of the study settings/project sites\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare providers were eligible for joining the CMHT and then participating in the study if they were over the age of 18 working with people with SMI in the five project sites. Additionally, peer workers (persons with lived experience of a SMI). over the age of 18 were asked to join the CMHT and to participated in this study. Each team had to consist of at least one nurse, psychiatrist, psychologist, social worker, and a peer worker. Healthcare professional and peer worker were excluded if they did not meet the inclusion criteria, did not give consent to participate in this study, or were not able to give consent to participate. Each team member of each project site participated on a voluntary basis and gave consent prior to the start of the study. Sampling and recruitment were organised by the local research team in each project site individually.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and recruitment \u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003eZagreb, Croatia\u003c/h3\u003e\n\u003cp\u003eDuring a daily meeting at the department of psychiatry at the University Hospital Centre Zagreb (ZUHC) the RECOVER-E project and its goals were presented. Healthcare professionals who were interested in this topic could approach the local principal investigator and decide if they want to participate. All healthcare professionals who accepted to become a part of the CMHT participated in this study, and were employees of the ZUHC. Peer workers were recruited from patients that were treated\u0026nbsp;at the ZUHC due to SMI and were recovered during psychosocial\u0026nbsp;treatment afterwards.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eKotor, Montenegro\u003c/h3\u003e\n\u003cp\u003eIn Montenegro CMHT members were employed by the Special Psychiatric Hospital in Kotor. They have been selected by the director of the clinic based on their commitment to work, their previous work results and on their own motivation and interest to work in this kind of programme and their awareness of the need to provide more than just hospital-based services for service users. The directors explained the project and the nature of the study and asked if they want to participate on a voluntary basis. In early October 2018 three peer worker were recruited from a group of locally treated clients at the hospital and the Mental Health Centre in Kotor. Inclusion criteria were a presence of severe mental health disorder, the willingness to participate in working activities of mental health\u0026nbsp;team, and the capacity to offer peer support based on the opinion of the treating psychiatrist. All healthcare proffesionals and peer workers who accepted to become a part of the CMHT participated in this study.\u003c/p\u003e\n\u003ch3\u003eSiret, Romania\u003c/h3\u003e\n\u003cp\u003eIn Romania CMHT members were selected out of the people working at the hospital in Siret by the local principle investigator. All team members were willing to spend some of their free time on pioneering a new service in mental health. Moreover, they were the most active during the on-site training provided by the project coordination. The peer worker was selected together by the social worker, psychiatrist and psychologist based on their professional experience. All healthcare professionals and the peer worker who accepted to become a part of the CMHT participated in this study.\u003c/p\u003e\n\u003ch3\u003eSkopje, North Macedonia\u003c/h3\u003e\n\u003cp\u003eAll CMHT members were employed at the University Clinic of Psychiatry Skopje and were recruited by the directors of the clinic. They selected the employees based on their willingness and motivation to try something new. The directors explained the project and the nature of the study and asked if they want to participate. The two peer workers, who were recruited, were treated\u0026nbsp;at the clinic due to SMI previously and were recovered during psychosocial\u0026nbsp;treatment. They are not employed at the clinic but were also selected by the directors of the clinic. Everybody took part in the first training that was organized in Skopje. All healthcare professionals and the peer worker who accepted to become a part of the CMHT also decided to participated in this study. Six members went to the second training in the Netherlands and updated the others.\u003c/p\u003e\n\u003ch3\u003eSofia, Bulgaria\u003c/h3\u003e\n\u003cp\u003eHealthcare providers were recruited by the director of the MHC Shipkovenski. They decided on a voluntary basis if they want to participate in this project. All CMHT members were employed at the MHC \u0026ldquo;Prof. N. Shipkovenski\u0026rdquo; a hospital for the district Sofia. The psychiatrists who work at the MHC Shipkovenski and those who collaborate with the centre suggested patients who were interested to fill in the role as peer workers. The director of the MHC Shipkovenski selected ten potential participants which participated in the training in July 2019. Three of them were invited and agreed to participate in the project. All healthcare professionals and the peer worker who accepted to become a part of the CMHT also decided to participated in this study.\u003c/p\u003e\n\u003ch2\u003eTraining on recovery-oriented practices\u003c/h2\u003e\n\u003cp\u003eAfter members of the CMHTs were appointed by each mental health service in the five sites, CMHT members participated in a two-week training programme, with one week of the training carried out in their home country and one week as an intensive site visit and training week in the Netherlands, hosted by GGZ Noord-Holland-Noord. In this training, healthcare professionals had the chance to improve their understanding of community based mental health approaches, with the aim of being able to implement a cohesive team in their city or district. The training programme for the CMHT were developed by a multidisciplinary Expert Panel (including a peer worker) and reviewed closely by the implementation site coordinators for local relevance and adaptation. The training covered key components of community mental health care, working with a shared caseload, and home treatments. It focused on building the hands-on skills and competencies necessary for delivering high quality community care, as well as working with peer specialists and families. A substantial component of the training (and subsequent mentoring and hands-on coaching) focused on the most difficult change process in building a sustainable CMHT, which is changing the mindset from viewing treatment for people with SMI as custodial (protection from communities/societies, care in institutions and hospitals) and shift to perceiving services as an aid to a meaningful life in the community.\u003c/p\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eData was collected using a paper-based survey administered among CMHT members at the local start of the study during a staff meeting in each site by the local research team after the first week of training in their home country (Table 2). The questionnaire items had been translated prior to the start of the study at each site into the local language by members of the local research team who were fluent in English and in the local language and back translated. It took the team members approximately 15 to 20 minutes to complete the questionnaire. An informed consent was signed by all selected staff members prior to the start of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable \u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e: Period of data collection and dates of the two training weeks per project site\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eMeasurements\u003c/h2\u003e\n\u003ch3\u003eSociodemographic data questionnaire\u003c/h3\u003e\n\u003cp\u003eThe sociodemographic part of the questionnaire included questions such as year of birth, sex, profession, years of professional experience, and place of work.\u003c/p\u003e\n\u003ch3\u003eRecovery Self-Assessment (RSA-Provider Version)\u003c/h3\u003e\n\u003cp\u003eThe Recovery Self-Assessment (RSA) is a 32-item measure developed to assess to what degree a program implements recovery-oriented practice (24). It is a self-reflective tool that is designed to identify efforts made by healthcare agencies to provided recovery-oriented care. Research has shown that the RSA has moderate to strong internal reliability (Cronbach\u0026rsquo;s \u0026alpha; 0.63 \u0026ndash; 0.90) (24-27). Response options include a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and two additional answering options (Don\u0026rsquo;t know and Not Applicable) (28). There are four different versions of the RSA: Person in recovery, Family member/advocate, provider, and CEOs/Directors. In this study the provider version (RSA-P) was used. The measure covers the following five subscales: Life Goals, Involvement, Diversity of Treatment Options, Choice, and Individually Tailored Services. The Life Goal domain refers to the extent to which staff helps with the development and achievement of life goals based on the preferences of the patient. Involvement indicates to what degree healthcare provider and clients perceive that clients are involved in their healthcare and in decision-making. Diversity of Treatment Option Subscale refers to what extend the healthcare organisation provides different treatment options and supports clients to get involved in non-mental health activities. The Choice domain indicates to what degree healthcare provider and clients feel that choices are available to clients and if the choice is respected. The subscale Individually Tailored Services refers to the perception that healthcare services are tailored to individuals\u0026rsquo; personal needs, culture and affectations (27). Higher scores indicate a greater degree of implementation of recovery-oriented practices (24).\u003c/p\u003e\n\u003ch3\u003eTeam Member Self-Assessment\u003c/h3\u003e\n\u003cp\u003eThe Team member Self-Assessment Tool (TMSA) developed by the Advancing Integrated Mental Health Solutions (AIMS) Centre of the University of Washington, Psychiatry \u0026amp; Behavioural Sciences Division of Population Health and is a part of the Team building and workflow guide (29). The tool (worksheet) consists of 26-items that allow each member of a care team to think about what collaborative care roles he/she currently practices. The worksheet includes five different care roles: Identify and Engage Patients, Track Treatment Outcome, Initiate, and Provide Treatment, Proactively Adjust Treatment if Patients are not responding, and other tasks Important for our Program. Response options for the first question \u0026ldquo;\u003cem\u003eIs this your role\u003c/em\u003e\u0026rdquo; include yes or no. Answering option for the second question \u0026ldquo;\u003cem\u003eYour level of comfort with this task\u003c/em\u003e\u0026rdquo; include high or medium/low.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eAll questionnaires were included in the analysis. Prior to analysis, all variables were checked for data entry errors and missing values. The two response options (\u0026lsquo;Don\u0026rsquo;t Know\u0026rsquo; and \u0026lsquo;Not Applicable\u0026rsquo;) were set as user missing value when conducting the first analysis since this is a common method for categorial variables with response options like \u0026lsquo;Not Applicable\u0026rsquo; or \u0026lsquo;Don\u0026rsquo;t Know\u0026rsquo;. Then the standard technique to calculate scale scores for each subscale of the RSA-P was used (30). This meant that, for each subscale all associate items were summarized and aggregate measures were constructed for further analysis for the whole sample as well as per project site. This method only allows for a few missing values. Thus, items with a high number (n \u0026gt; 6) of \u0026lsquo;Not Applicable\u0026rsquo; responses were reviewed and discussed with the local research teams of each site to understand in what way this response option was interpreted by the CMHT members who completed the questionnaire. Most of these items turned out to be relating to services/treatment options which were not offered by the hospitals, the mental health institutes or not within the scope of the RECOVER-E project. Thus, the answering option \u0026lsquo;Not Applicable\u0026rsquo; was combined with \u0026lsquo;Strongly Disagree\u0026rsquo; in the second and final analysis, as both indicated that those services were not provided. Bivariate linear regression analyses were applied to explore the impact of predictors on the five aggregate measures for the whole sample. Predictors with significant effects were included in multiple regression models, albeit these were considered as highly tentative given the small sample size. The internal consistency of the RSA-P and its five subscales were evaluated using Cronbach\u0026rsquo;s alpha coefficient.\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to calculate the means and standard deviations for continuous variables and frequencies and percentages for categorical variables for the TMSA tool and demographic data. For interpretation of the findings the cut-off points for the TMSA tool for each profession was 50% indicated that half of the given profession felt like a listed role is their responsibility or that half of them felt confident to fulfil these roles. Two participants indicated \u0026lsquo;other\u0026rsquo; as profession and were excluded TMSA analysis. Data was analysed with the Statistical Package for Social Science SPSS version 25 (31). Statistical significance was defined as p\u0026lt;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eDescription of the sample\u003c/h2\u003e\n\u003cp\u003eAll team members from each site filled in the questionnaire (n=66). Table 3 presents the descriptive characteristics of the sample categorised by countries. The largest community mental health team was the Croatian team with 21 (31.8% of the total sample), the smallest team was the Romanian team with 6 (9.1% of the sample) individuals. Of the total study population 65.2% (n=43) were female. The mean age was 40.02 (SD=10.96) years. A third of the participating professionals were nurses (31.8%). A vast majority of the healthcare professionals had more than five years of experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable \u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e: Description of the study population (n= 66 healthcare professionals and peer worker) per project site\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eRecovery Self-Assessment Provider Version (RSA-P)\u003c/h2\u003e\n\u003ch2\u003eOverall Recovery Self-Assessment Scale\u003c/h2\u003e\n\u003cp\u003eThe members of the CMHT in Romania and Bulgarian reported the highest means of the RSA-P subscales, with an overall scale 4.46 (SD 0.327) and 4.46 (SD 0.211), respectively. The team members of the Croatian team reported an overall mean of 4.16 (SD 0.404). The lowest means were indicated by the Macedonian team 4.05 (SD 0.694) and the Montenegrin team 3.58 (SD 0.275). This pattern was similar for the different subscales (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable \u003c/strong\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003cstrong\u003e: Recovery Self-Assessment Scale (Provider Version) per project site\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eAssociations between individual characteristics and Recovery Self-Assessment\u003c/h2\u003e\n\u003cp\u003eProfession (p=0.029, beta coefficient= 0.271) and professional experience (p=0.008, beta coefficient= -0.328) were associated with the total RSA-P score. However, only professional experience (p=0.036, beta coefficient= -0.268) remained significant in the multiple regression analysis with both predictors. The effect of professional experience on the total RSA-P implied that healthcare providers with fewer years of professional experience were more likely to perceive that their healthcare practice operated recovery-oriented compared to team members with more years of professional experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRSA-P-Subscales:\u003c/strong\u003e The amount of professional experience had an impact on the degree to what healthcare provider perceived choices are available to clients and if these choices are respected (p=0.027, beta coefficient= -0.286). More specifically, professionals with fewer years of professional experience were more likely to perceive that individual choices are available to clients and that these choices are respected than with team members with more years of work experience. Additionally, work experience (p=0.003, beta coefficient= -0.357) and profession (p=0.012, beta coefficient= 0.311) were associated with the extent to which staff helps with the development and achievement of life goals based on the preferences of the patients. In the multiple regression analysis with both predictors, only professional experience remained significant (p=0.023, beta coefficient= -0.286,). Thus, CMHT members with more years of professional experience perceived that their role was less supportive regarding helping clients with achieving and developing their individual life goals. Healthcare provider with less years of work experience had a higher tendency to perceive that clients are involved in their healthcare and in decision-making compared to their those with more years of experience (p=0.016, beta coefficient= -0.311). Professionals with more years of work experience felt less like their healthcare organisation provides different treatment options or supports clients to get involved in non-mental health activities (p=0.017, beta coefficient= -0.302). The expected effect of professional experience on the subscale Individually Tailored Services was not significant although close (p=0.051, beta coefficient= -0.251).\u003c/p\u003e\n\u003ch2\u003eTeam Member Self-Assessment\u003c/h2\u003e\n\u003cp\u003eThe findings of the TMSA are reported by professions. More than 50% indicate that a majority of members of a profession saw themselves in a certain role and/or felt highly confident in fulfilling these roles. The questionnaire was completed after the healthcare professionals received the first week of training, and started to work as CMHTs. Thus, it is to expected they evaluated their role and responsibilities within the team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNurses:\u003c/strong\u003e A large majority of the nurses (n=81.0%) saw themselves in the role of identifying and engaging patients. Nevertheless, only a small number (n=33.3%) stated that they feel highly confident to fulfil the different responsibilities within this role on the CMHT. A third stated that diagnosing behavioural health disorders is their responsibility (n= 33.3%). Over 50% also saw themselves as having a role in tracking treatment outcomes, although only a few felt confident to fulfil this role. A vast majority of nurses saw their role in different responsibilities within this role as well, such as by conducting behavioural health assessments, developing and updating behavioural health treatment plans, educating patient about symptoms and treatment option, brief counselling, activity scheduling, behavioural activation, facilitating referral to specialty care or social services, and creating and supporting relapse prevention plan. However, only a few felt confident to fulfil these responsibilities. A large majority of nurses also stated that proactively adjust treatment if patients are not responding is their role, however less than a third of them felt confident to fulfil these roles. Although other tasks like e.g. administrative support for program (scheduling, resources) is a role more than 50% of the nurses also saw themselves in, only a few felt confident to fulfil these roles (Table 5 \u0026ndash; 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychiatrists\u003c/strong\u003e: The large majority of psychiatrists saw themselves in all listed roles, and also felt confident to fulfil these roles. They particularly identified with the role of tracking treatment outcomes and initiating and providing treatment (Table 5 \u0026ndash; 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychologists: \u003c/strong\u003eA vast majority of psychologists identified with all roles listed and felt highly confident to fulfil these roles. Although they felt like they were responsible for some tasks such as prescribing psychotropic medications, patient education about medications and side effects, identifying and treating coexisting medical conditions, and facilitating referral to specialty care or social services of within the role of tracking treatment outcomes, they saw themselves more in the roles of identifying and engaging patients and initiating and providing treatment (Table 5 \u0026ndash; 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocial workers:\u003c/strong\u003e A majority of social workers saw themselves in all roles listed, but did not feel confident to fulfil these roles. All social workers stated that they were responsible for identifying people who may need help, engaging patients and introducing the care team to the patient. Interestingly, all social workers saw themselves in the role of tracking outcome of referrals and other treatments, but only two felt confident to fulfil this role (n=25.0%). Initiate and provide treatment is a role mainly psychiatrists identified with; however, all social workers stated that they saw themselves in facilitate referral to specialty care or social services and create and support relapse prevention plans, and indicated feeling highly confident to fulfil these tasks (Table 5 \u0026ndash; 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeer workers:\u003c/strong\u003e Almost all peer workers saw themselves in the role of engaging patients in the care program and introduce care team to the patient (n=78.6%), only around a third felt confident to fulfil this role (n=28.6%). Interestingly, more than half of peer workers saw themselves in the role of tracking treatment outcomes, except for tracking patients\u0026rsquo; symptoms with measurement tools, although they did not feel confident to fulfil this role. They also stated to be responsible for some tasks within the role of initiating and providing treatment like performing behavioural health assessment, develop and update behavioural health treatment plan, patient education about symptoms and treatment option, and brief counselling, activity scheduling, behavioural activation. However, they only felt confident to fulfil the task of educating patients about symptoms and treatment options. Less than 50% felt responsible for the role of proactively adjusting treatment if patients are not responding. Half of the peer workers identified with the role of fulfilling other tasks important for the program, nevertheless only a few felt confident enough to fulfil this role (Table 5 \u0026ndash; 7).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Team Member Self-Assessment tool: Identify and Engage Patients and Track Treatment Outcome \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Team Member Self-Assessment tool: Initiate and provide treatment \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7: Team Member Self-Assessment tool: Proactively adjust treatment if patients are not responding and other tasks important for our project \u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe overall aim of this study was to explore to what degree members of the five CMHTs had introduced aspects of the recovery-oriented practice in community settings after they received the first week of a two-weeks of training session covering the concept of recovery-oriented practice and started to work as CMHT. The secondary aim was to evaluate what the team members think about what collaborative care roles they currently practice within the CMHT, how confident they feel with this role, and to explore differences between the professions involved.\u003c/p\u003e\n\u003cp\u003eIn general, we found out that all CMHTs had the perception that they provide recovery-oriented practices to a moderately high degree base on the findings of the RSA-P. Nevertheless, specific aspects such as connecting clients with self-help, peer support or advocacy groups and programs, and encouraging them to attend advisory boards and management meetings showed room for enhanced implementation. Healthcare professionals with less professional experience had the tendency to perceive that their healthcare practice implemented recovery-oriented practice compared to team members with a higher degree of professional experience. Nurses saw themselves mainly in the role of identifying and engaging patients, tracking treatment outcomes, proactively adjusting treatment if patients are not responding and other tasks important for this project. Nevertheless, compared to the psychiatrists and psychologists, most of the nurses did not feel confident to fulfil specific roles. Psychiatrists, psychologists, and social workers saw themselves in almost all roles listed. In comparison with the psychologists and social workers, psychiatrists felt highly confident to fulfil each role. Peer workers mainly saw themselves in the role of engaging patients and fulfil other tasks important to the project. Nevertheless, they did not feel confident to fulfil specific roles. Interestingly, a majority of peer workers saw themselves in roles included within the domain of track treatment outcomes and initiate and provide treatment.\u003c/p\u003e\n\u003cp\u003eIn 2013, the WHO released the Mental Health Action Plan (32) stating the need for availability of recovery-oriented mental health services in the community. In our study, all CMHTs had already introduced various aspects of recovery-oriented practices. However, it needs to be considered that most team members were highly enthusiastic about community care prior to the start of the project which might had a positive impact on the results. This findings are consistent with those by Simmonds et al. (22), they reported that a high level of enthusiasm for community care has been seen by all members of CMHTs which have been evaluated. Nevertheless, it cannot be concluded that enthusiasm and motivation alone have an impact on the quality of care provided by healthcare professionals. Additionally, members of each CMHTs of this study have been selected by the research team based on their commitment or were motivated to be part of this project. Thus, it is possible that the motivation to provide recovery-oriented care within the teams is higher compared to healthcare providers who have not been selected or are not interested in community care. These findings are consistent with those by Malone et al. (6). They conducted a systematic review on the effects of CMHT management compared to non-research CMHT management. All healthcare professional working as CMHT included in their review have been selected or linked to the research programme. Hence, it is not clear if the results can be generalised from selected or highly committed professionals to non-selected professionals. The same applies to the findings of this study. The members of each CMHT of this study attended the first week of two-weeks training on the concept of recovery provided by the coordinating project team. This training might have a positive impact on the perceptions of the healthcare provider regarding degree of recovery-oriented care within their organisation. These findings agree with those of Hornik-Lurie et al. (12). In their study they found out that staff which had been trained in recovery-oriented interventions had higher perceptions of recovery-oriented care compared to nontrained staff (12). Thus, training on recovery-oriented practices may be an effective strategy to facilitate implementation of this care approach.\u003c/p\u003e\n\u003cp\u003eIn this study, higher RSA-P scores and thus the tendency to perceive that more aspects of recovery-oriented practice were introduced were detected in healthcare professionals with limited professional experience. Since the Substance Abuse and Mental Health Services Administration (SAMHSA) of the US incorporated a curriculum on recovery-oriented care into the training of mental health professionals in 2009, the recovery-oriented approach has become more conversant (33). Thus, it is possible that the younger generation is more trained in the principles of the recovery-oriented approach due to changes to the curriculum over the last years (33).\u003c/p\u003e\n\u003cp\u003eCMHT members of this study, especially nurses and peer workers, are not always aware of their role or responsibilities or do not feel confident to fulfil specific roles. It makes sense that for example nurses do not feel confident doing some of the tasks that a psychiatrist usually does, as it is not necessarily their role in the teams, it may be something that they have not been trained for and/or it is something that they are legally not allowed to. Moreover, it may be due to the specific training/education these professionals acquire through their university career as well as longstanding traditions. In Croatia for example university level education of nurses is very new (34). Thus, nurses may have not yet acquired their professional identity. This might have an impact on how nurses identified with certain roles and responsibilities. Additionally, peer workers, in general, do not have any specific peer support education to define their professional identity. This findings are consistent with those by Carpenter et al. (35); in their study they investigated the impact of working in multidisciplinary CMHTs in North England on social workers and health professionals. They particularly examined the relationship between team identification, team functioning, psychological well-being and job satisfaction (35). Although they found out that there is a moderate to high level of role clarity within the members of CMHTs, various role conflicts were detected (35). Conflicts included disagreements between professions or discipline, workload, misunderstandings of roles and responsibilities or an increase in paperwork (35). Carpenter et al. (35) concluded that role clarity promoted job satisfaction and decreases work related stress. In our study role clarity seems to be problematic, thus conflicts and disagreements may be pre-programmed. In addition, psychiatrists, psychologist, and social workers saw themselves in almost all listed roles, regardless of being confident to fulfil those roles, an unclear division of roles impeded effective team collaboration and cooperation. The existing stigmatisation in the society and among healthcare professionals may had an impact on the role of peer workers. The fact that peer workers are more and more involved in providing mental health care requires a huge shift in the way mental health professionals think. Additionally, the level of self-stigmatisation among peers may be very high and influencing these results of this study as well (36).\u003c/p\u003e\n\u003cp\u003eAnother source of role conflict detected by Carpenter et al. (35) was inadequate allocation of resources for people with SMI e.g. access to appropriate service based on individual needs. These findings agree with those by Singh (18), in his study he reported that the rapid reduction of beds for people with SMI had an negative impact on the care provided by CMHTs. Although CMHTs may operate effectively, a majority of patients with SMI need to be admitted to acute hospital care to receive the care they need (18). Thus, access to an adequate number of acute beds and hospital care is necessary not only for patients with SMI but also for CMHTs to provide effective community-based mental health care and to avoid conflicts.\u003c/p\u003e\n\u003ch2\u003eImplications for practice and policy\u003c/h2\u003e\n\u003cul\u003e\n\u003cli\u003eIt is important that CMHTs consist of healthcare professionals with a wide range of professional experience and different competences to ensure high quality of community-based mental health services.\u003c/li\u003e\n\u003cli\u003eRole clarity, particularly the role of nurses and peer workers, is important to run CMHTs effectively and to avoid conflicts within the teams.\u003c/li\u003e\n\u003cli\u003eMore training and different steps for ensuring team cohesion may be necessary.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\n\u003cp\u003eThe study had a high participation rate and used some validated measures. However, this is a descriptive study in five mental health centres in different Eastern and Central Europe countries, hence the generalizability of the findings is uncertain. Moreover, all healthcare providers of all five CMHT volunteered to be part of a mobile team, so their personal commitment and their own motivation might influence the results positively compared to healthcare provider who are not involved in such a project. In addition, results may be driven by particular countries due to the difference in sample size. Due to relatively small sample sizes per country, country-specific analysis cannot be performed.\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eTrainings on community-based practices and collaborative teamwork may enhance recovery-oriented practice and helps to allocate roles and responsibilities clearly. Recovery-oriented care is a complex concept which requires time, skills and professional mindset to shift different care approaches to this new way of working. Thus, investments are needed to support CMHT members to gradually shift towards seeing strengths and weaknesses of providing community-based recovery-oriented care and being a part of the recovery process of patients rather than being leading role of this process. Furthermore, roles and responsibilities within the CMHT should be clear to everyone, particularly the role of peer workers. Additional training is needed support the role of peer workers within the CMHT and enhance their self-esteem.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eWHO:\u003c/strong\u003e World Health Organisation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSMI:\u003c/strong\u003e Severe Mental Illness\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCMHT:\u003c/strong\u003e Community Mental Health Team\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRECOVER-E:\u003c/strong\u003e Large-scale implementation of community-based mental health care for people with severe and enduring mental ill health in Europe\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRSA-P:\u003c/strong\u003e Recovery self-assessment tool Provider Version\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTMSA:\u003c/strong\u003e Team Member Self-Assessment Tool\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval\u003c/h2\u003e\n\u003cp\u003eEthics approval was obtained of the Medical Ethics Committee of the Medical Faculty Heidelberg (S-496/2018) prior to the start of the study in August 2018 by the Heidelberg Team. Additionally, each study in each implementation site has received ethical approval from a local institutional review board prior to the start of the study:\u003c/p\u003e\n\u003cp\u003eName of the committee for Zagreb, Croatia: Ethics Committee of the University Hospital Centre (UHC) Zagreb; Ethical approval: 18.07.2018, Number: 02/21 AG, Class 8.1-18/149-2\u003c/p\u003e\n\u003cp\u003eName of the committee for Kotor, Montenegro: Ethics Committee of the HI Specialized Psychiatric Hospital Dobrota Kotor, Ethical approval: 28.09.2018, Number 3463/1\u003c/p\u003e\n\u003cp\u003eName of the committee for Suceava, Romania: Ethics Council Chronic Psychiatric Hospital Siret, Ethical approval: 21.11.2018\u003c/p\u003e\n\u003cp\u003eName of the committee for Skopje, North Macedonia: Ethical Committee for Research on Human Subjects, Medical Faculty, SS Cyril and Methodius University Skopje, Skopje, North Macedonia; Ethical approval: 21.05.2018\u003c/p\u003e\n\u003cp\u003eName of the committee for Sofia, Bulgaria: Commission of Ethics at the National Centre of Public Health and Analyses, Sofia, Bulgaria; Ethical approval: 25.01.2019.\u003c/p\u003e\n\u003cp\u003eThe study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003ch2\u003eConsent to participate\u003c/h2\u003e\n\u003cp\u003eWritten informed consent was obtained\u0026nbsp;from\u0026nbsp;all participants before enrolment.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and material\u003c/h2\u003e\n\u003cp\u003eThe dataset generated and analysed during the current study will not be made publicly available due to European Data Protection Law but maybe available by the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis project has received funding from the European Union\u0026rsquo;s Horizon 2020 research and innovation programme under Grant Agreement 779362.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eMW and LSZ conceived this study and elaborated the research protocol. CR wrote the manuscript. All authors provided substantial comments and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to thank all healthcare professionals who participated in this study and contribute to the improvement of mental health care. Moreover, would we like to acknowledges the mandate and funding for this project from the European Union\u0026rsquo;s Horizon 2020 Research and Innovation Programme and the Global Alliance for Chronic Disease.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. The Lancet. 2007;370(9590):841-50.\u003c/li\u003e\n\u003cli\u003eVos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990\u0026ndash;2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015;386(9995):743-800.\u003c/li\u003e\n\u003cli\u003eKohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Organ. 2004;82(11):858-66.\u003c/li\u003e\n\u003cli\u003eMitchell AJ, Malone D, Doebbeling CC. Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies. British Journal of Psychiatry. 2009;194(6):491-9.\u003c/li\u003e\n\u003cli\u003eGutierrez-Colosia MR, Salvador-Carulla L, Salinas-Perez JA, Garcia-Alonso CR, Cid J, Salazzari D, et al. Standard comparison of local mental health care systems in eight European countries. Epidemiology and Psychiatric Sciences. 2019;28(2):210-23.\u003c/li\u003e\n\u003cli\u003eMalone D, Newron-Howes G, Simmonds S, Marriot S, Tyrer P. Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality. Cochrane Database Syst Rev. 2007(3):CD000270.\u003c/li\u003e\n\u003cli\u003evan Veldhuizen JR. FACT: a Dutch version of ACT. Community Ment Health J. 2007;43(4):421-33.\u003c/li\u003e\n\u003cli\u003eKhoury E. Recovery Attitudes and Recovery Practices Have an Impact on Psychosocial Outreach Interventions in Community Mental Health Care. Front Psychiatry. 2019;10:560-.\u003c/li\u003e\n\u003cli\u003eDavidson L, O'Connell M, Tondora J, Styron T, Kangas K. The Top Ten Concerns About Recovery Encountered in Mental Health System Transformation. Psychiatric Services. 2006;57(5):640-5.\u003c/li\u003e\n\u003cli\u003eBoardman J, Shepherd G. RECOVERY: Implementing recovery in mental health services. Int Psychiatry. 2012;9(1):6-8.\u003c/li\u003e\n\u003cli\u003eOsborn LA, Stein CH. Community Mental Health Care Providers' Understanding of Recovery Principles and Accounts of Directiveness with Consumers. Psychiatr Q. 2017;88(4):755-67.\u003c/li\u003e\n\u003cli\u003eHornik-Lurie T, Shalev A, Haknazar L, Garber Epstein P, Ziedenberg-Rehav L, Moran GS. Implementing recovery-oriented interventions with staff in a psychiatric hospital: A mixed-methods study. Journal of Psychiatric and Mental Health Nursing. 2018;25(9-10):569-81.\u003c/li\u003e\n\u003cli\u003eAndresen R, Caputi P, Oades L. Stages of recovery instrument: development of a measure of recovery from serious mental illness. Australian and New Zealand Journal of Psychiatry. 2006;40(11-12):972-80.\u003c/li\u003e\n\u003cli\u003eGillard S, Holley J. Peer workers in mental health services: literature overview. Advances in Psychiatric Treatment. 2018;20(4):286-92.\u003c/li\u003e\n\u003cli\u003eLeff J, Trieman N. Long-stay patients discharged from psychiatric hospitals: Social and clinical outcomes after five years in the community. the TAPS Project 46. British Journal of Psychiatry. 2000;176(3):217-23.\u003c/li\u003e\n\u003cli\u003eTrieman N, Leff J, Glover G. Outcome of long stay psychiatric patients resettled in the community: prospective cohort study. BMJ. 1999;319(7201):13-6.\u003c/li\u003e\n\u003cli\u003eCaldas de Almeida J, Killaspy H. Long Term Mental Health Care for People with Severe Mental Disorders. 2011.\u003c/li\u003e\n\u003cli\u003eSingh SP. Running an effective community mental health team. Advances in Psychiatric Treatment. 2018;6(6):414-22.\u003c/li\u003e\n\u003cli\u003eHaines A, Perkins E, Evans EA, McCabe R. Multidisciplinary team functioning and decision making within forensic mental health. Ment Health Rev (Brighton). 2018;23(3):185-96.\u003c/li\u003e\n\u003cli\u003eCaldas Almeida J, Mateus P, Tom\u0026eacute; G, Katschnig H, Hinkov H, Sooniste I. Joint Action on Mental Health and Well-Being, Towards Community-Based and Socially Inclusive Mental Health Care, Situation Analysis and Recommendations for Action. 2016.\u003c/li\u003e\n\u003cli\u003eBond G, Drake R, Mueser K, Latimer E. Assertive Community Treatment for People with Severe Mental Illness. Disease Management and Health Outcomes. 2001;9(3):141-59.\u003c/li\u003e\n\u003cli\u003eSimmonds S, Coid J, Joseph P, Marriott S, Tyrer P. Community mental health team management in severe mental illness: a systematic review. Br J Psychiatry. 2001;178(6):497-502; discussion 3-5.\u003c/li\u003e\n\u003cli\u003eShields-Zeeman L, Petrea I, Smit F, Walters BH, Dedovic J, Kuzman MR, et al. Towards community-based and recovery-oriented care for severe mental disorders in Southern and Eastern Europe: aims and design of a multi-country implementation and evaluation study (RECOVER-E). Int J Ment Health Syst. 2020;14(1):30.\u003c/li\u003e\n\u003cli\u003eO'Connell M, Tondora J, Croog G, Evans A, Davidson L. From rhetoric to routine: assessing perceptions of recovery-oriented practices in a state mental health and addiction system. Psychiatr Rehabil J. 2005;28(4):378-86.\u003c/li\u003e\n\u003cli\u003eWilliams J, Leamy M, Bird V, Harding C, Larsen J, Le Boutillier C, et al. Measures of the recovery orientation of mental health services: Systematic review. Social psychiatry and psychiatric epidemiology. 2012;47(11):1827-35.\u003c/li\u003e\n\u003cli\u003eSalzer MS, Brusilovskiy E. Advancing Recovery Science: Reliability and Validity Properties of the Recovery Assessment Scale. Psychiatric Services. 2014;65(4):442-53.\u003c/li\u003e\n\u003cli\u003eKonkoly Thege B, Ham E, Ball LC. A Factor Analytic Investigation of the Person-in-Recovery and Provider Versions of the Revised Recovery Self-Assessment (RSA-R). Eval Health Prof. 2017;40(4):505-16.\u003c/li\u003e\n\u003cli\u003ePiat M, Boyer R, Fleury M-J, Lesage A, O'Connell M, Sabetti J. Resident and proprietor perspectives on a recovery orientation in community-based housing. Psychiatric rehabilitation journal. 2015;38(1):88-95.\u003c/li\u003e\n\u003cli\u003eTeam building and workflow guide: University of Washington \u0026ndash; AIMS Center 2019 [cited 2020 21. January ]. Available from: https://aims.uw.edu/resource-library/team-building-and-workflow-guide.\u003c/li\u003e\n\u003cli\u003eO'Connell M. Recovery Self-Assessment (RAS): Scoring instructions and factors. 2019.\u003c/li\u003e\n\u003cli\u003eWagner III WE. Using IBM\u0026reg; SPSS\u0026reg; statistics for research methods and social science statistics: Sage Publications; 2019.\u003c/li\u003e\n\u003cli\u003eSaxena S, Funk M, Chisholm D. World Health Assembly adopts Comprehensive Mental Health Action Plan 2013-2020. Lancet. 2013;381(9882):1970-1.\u003c/li\u003e\n\u003cli\u003eSowers W, Primm A, Cohen D, Pettis J, Thompson K. Transforming Psychiatry: A Curriculum on Recovery-Oriented Care. Acad Psychiatry. 2016;40(3):461-7.\u003c/li\u003e\n\u003cli\u003eKalauz S, Orlic-Sumić M, Simunec D. Nursing in Croatia: past, present, and future. Croat Med J. 2008;49(3):298-306.\u003c/li\u003e\n\u003cli\u003eCarpenter J. Working in Multidisciplinary Community Mental Health Teams: The Impact on Social Workers and Health Professionals of Integrated Mental Health Care. British Journal of Social Work. 2003;33(8):1081-103.\u003c/li\u003e\n\u003cli\u003eVandewalle J, Debyser B, Beeckman D, Vandecasteele T, Van Hecke A, Verhaeghe S. Peer workers' perceptions and experiences of barriers to implementation of peer worker roles in mental health services: A literature review. Int J Nurs Stud. 2016;60:234-50.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Characteristics of the study settings/project sites\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u003cstrong\u003eZagreb, Croatia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u003cstrong\u003eKotor, Montenegro\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u003cstrong\u003eSiret, Romania\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u003cstrong\u003eSkopje, Macedonia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u003cstrong\u003eSofia, Bulgaria\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e\u003cstrong\u003eCatchment area (inhabitants) \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;980.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e89.000 (initially/at beginning of the study) 165.000 enlarged from October 2019**\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;100.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;500.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;1.300.000****\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal number \u003c/strong\u003e\u003cstrong\u003eof psychiatric\u003c/strong\u003e\u003cstrong\u003epatients in \u003c/strong\u003e\u003cstrong\u003ecatchment area\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;12.226\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e9.000 (initially / at the beginning of thy study)16.000 *enlarged / from October 2019***\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;51.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;30.000*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;27.000*****\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e\u003cstrong\u003eCMHT staff structure \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003ePsychiatrists, Psychologist, Nurses, Social Worker,Non-mental health Professionals\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003ePsychiatrists, Psychologist, Nurses\u0026nbsp; Social Worker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003ePsychiatrists, Psychologist, Nurses, Social Worker, Occupational therapists\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003ePsychiatrists, Psychologist, Nurses, Social Worker, Psychiatric Trainees, Occupational Therapists, Disability Therapists\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003ePsychiatrists, Psychologist, Nurses, Social Worker\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e\u003cstrong\u003eType of services for people with mental health issues \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003eInpatient treatment (acute and chronic care) Psychotherapeutic inpatient care,Outpatient visits 1 per months and daily hospital for first episode psychosis and schizophreniaMobile team since 2017\u003c/td\u003e\n\u003ctd width=\"168\"\u003eInpatient and outpatient treatment (acute and chronic care)\u0026nbsp;Community based mental health service since 2010\u003c/td\u003e\n\u003ctd width=\"168\"\u003eInpatient and outpatient treatment (acute and chronic care)\u003c/td\u003e\n\u003ctd width=\"168\"\u003eInpatient and outpatient treatment (acute and chronic care)\u003c/td\u003e\n\u003ctd width=\"168\"\u003eInpatient and outpatient treatment (acute and chronic care)\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"133\"\u003e\u003cstrong\u003eFinancing of mental health services \u003c/strong\u003e\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003eCroatian Health Insurance Fund\u003c/p\u003e\n\u003cp\u003eOut-of-pocket costs are not significant\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003eNational Health Insurance Fund (Bismarck\u0026rsquo;s model of financing) Funds from donations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003eRomanian Health Insurance Fund through the DRG system\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003eMacedonian Health Insurance Fund\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003eState financing Municipality National Health Insurance Fund and Out-of-pocket\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u0026nbsp;\u0026nbsp;\u0026nbsp; Clinic of Psychiatry, Psychiatric hospital Skopje and outpatients MH Services\u003c/p\u003e\n\u003cp\u003e** \u0026nbsp;Census of Population in Montenegro 2011 / http://www.monstat.org/userfiles/file/popis2011/saopstenje/saopstenje(1).pdf\u003c/p\u003e\n\u003cp\u003e*** Data gathered from hospital and mental health centres in each municipality (free estimation / there is no published source)\u003c/p\u003e\n\u003cp\u003e**** https://www.nsi.bg/en/content/6704/population-districts-municipalities-place-residence-and-sex\u003c/p\u003e\n\u003cp\u003e*****Data form NCPHA database\u0026nbsp; (not published)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Period of data collection and dates of the two training weeks per project site\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e\u003cstrong\u003eZagreb, \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCroatia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e\u003cstrong\u003eKotor, Montenegro\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e\u003cstrong\u003eSiret, \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRomania\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e\u003cstrong\u003eSkopje, North Macedonia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e\u003cstrong\u003eSofia, \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBulgaria\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003ePeriod of Recruitment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003eMay 2018 \u0026ndash; September 2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1. \u0026ndash; 15.\u003c/p\u003e\n\u003cp\u003eOctober 2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003eJanuary 2018 and March 2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e20. \u0026ndash; 31. May 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003eApril 2019 \u0026ndash;\u003c/p\u003e\n\u003cp\u003eJune 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eTraining Week 1 (on-site-training)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e24. \u0026ndash; 28. September 2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e4. \u0026ndash; 8.\u003c/p\u003e\n\u003cp\u003eNovember 2018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e28. January \u0026ndash; 02. February 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e24. \u0026ndash; 28.\u003c/p\u003e\n\u003cp\u003eJune 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e15. \u0026ndash; 19.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;July 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eData collection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003eFebruary 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003eFebruary 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003eApril 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003eJune 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003eNovember 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eTraining Week 2 (Netherlands)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e6. \u0026ndash; 10.\u003c/p\u003e\n\u003cp\u003eMay 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e6. \u0026ndash; 10.\u003c/p\u003e\n\u003cp\u003eMay 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"129\"\u003e\n\u003cp\u003e6. \u0026ndash; 10.\u003c/p\u003e\n\u003cp\u003eMay 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"119\"\u003e\n\u003cp\u003e02. \u0026ndash; 06. December 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e02. \u0026ndash; 06. December 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Description of the study population (n= 66 healthcare professionals and peer worker) per project site\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003e\u003cstrong\u003eProject site \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eZagreb, \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCroatia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en= 21\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eKotor, Montenegro\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=15\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eSiret, \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRomania\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en= 6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eSkopje, North Macedonia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=10\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eSofia,\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Bulgaria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=14\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=66\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e15 (71.4%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 6 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 9 (60.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 6 (40.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (66.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 5 (50.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 5 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e10 (71.4%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (28,6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e43 (65.2%)\u003c/p\u003e\n\u003cp\u003e23 (34.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMean (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e41.3 (12.56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e38.47 (9.71)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e43.67 (6.98)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e39.10 (11.22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e38.93 (11.83)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e40.02 (10.96)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003e\u003cstrong\u003eProfession \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurse\u003c/p\u003e\n\u003cp\u003ePsychiatrist\u003c/p\u003e\n\u003cp\u003ePsychologist\u003c/p\u003e\n\u003cp\u003eSocial worker\u003c/p\u003e\n\u003cp\u003ePeer worker\u003c/p\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 9 (42.9%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (19.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1\u0026nbsp;\u0026nbsp; (4.8%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3 (14.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (19.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 5 (33.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (26.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (13.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1\u0026nbsp;\u0026nbsp; (6.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3 (20.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (33.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (16.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (16.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (16.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (16.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0 (16.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (20.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (20.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (20.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (10.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (20.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (10.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3 (21.4%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (14.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3 (21.4%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (14.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (28.6%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e21 (31.8%)\u003c/p\u003e\n\u003cp\u003e13 (19.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 9 (13.6%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 8 (12.1%)\u003c/p\u003e\n\u003cp\u003e14 (21.2%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1\u0026nbsp;\u0026nbsp; (1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"217\"\u003e\n\u003cp\u003e\u003cstrong\u003eProfessional Experience\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLess than one year\u003c/p\u003e\n\u003cp\u003eBetween one and two years\u003c/p\u003e\n\u003cp\u003eBetween two and three years\u003c/p\u003e\n\u003cp\u003eBetween three and four years\u003c/p\u003e\n\u003cp\u003eBetween four and five years\u003c/p\u003e\n\u003cp\u003eMore than five years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1\u0026nbsp;\u0026nbsp;\u0026nbsp; (4.8%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3\u0026nbsp; (14.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2\u0026nbsp;\u0026nbsp;\u0026nbsp; (9.5%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1\u0026nbsp;\u0026nbsp;\u0026nbsp; (4.8%)\u003c/p\u003e\n\u003cp\u003e14\u0026nbsp; (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2 (13.3%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e13 (86.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (16.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (16.7%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (10.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (10.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1 (10.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3 (30.0%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (40.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (28.6%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3 (21.4%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 0\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 7 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 8 (12.1%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 5 (7.6%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3 (4.5%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (6.1%)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4 (6.1%)\u003c/p\u003e\n\u003cp\u003e42 (63.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*Team size varies due different local human resources \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTable 4:\u003c/strong\u003e Recovery Self-Assessment Scale (Provider Version) per project site \u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"712\"\u003e\n\u003cp\u003e\u003cstrong\u003eProject sites\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e\u003cstrong\u003eRSA-P subscale, mean (standard deviation)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e\u003cstrong\u003eZagreb, \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCroatia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eKotor, Montenegro\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eSiret, Romania\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eSkopje, \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMacedonia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003e\u003cstrong\u003eSofia, Bulgaria\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e\u003cstrong\u003eLife Goals\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e4.09 (0.456)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e3.74 (0.327)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.64 (0.368)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.02 (0.684)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003e4.38 (0.281)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e\u003cstrong\u003eInvolvement\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e3.84 (0.568)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e2.67 (0.645)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.63 (0.446)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e3.95 (0.880)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003e4.57 (0.312)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e\u003cstrong\u003eDiversity of treatment option\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e4.17 (0.536)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e3.07 (0.230)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.60 (0.357)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.05 (0.754)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003e4.70 (0.188)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e\u003cstrong\u003eChoice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e4.44 (0.433)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.53 (0.317)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.48 (0.349)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.02 (0.722)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003e4.79 (0.146)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e\u003cstrong\u003eIndividually tailored service\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e3.99 (0.457)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e3.35 (0.470)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.71 (0.368)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.06 (0.914)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003e4.63 (0.235)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"200\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal RSA-P \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e4.16 (0.404)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e3.58 (0.275)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.46 (0.327)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4.05 (0.694)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003e4.46 (0.211)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u003c/strong\u003e Team Member Self-Assessment tool: Identify and Engage Patients and Track Treatment Outcome\u003c/p\u003e\n\u003ctable style=\"width: 732px;\" border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 197px;\" colspan=\"2\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn total n=65 professionals\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eNurse\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=21 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e\u003cstrong\u003ePsychiatrist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=13 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e\u003cstrong\u003ePsychologist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=9 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocial worker\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=8 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e\u003cstrong\u003ePeer worker\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=14 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 689px;\" colspan=\"7\"\u003e\n\u003cp\u003e\u003cstrong\u003eIdentify and Engage Patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eIdentify People who may need help\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e17 (81.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e8 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e3 (21.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e7 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e6 (75.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e2 (14.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eScreen for behavioural health problems using valid measures\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e13 (61.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e12 (92.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e5 (23.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e6 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e2 (25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eDiagnose behavioural health disorders\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e7 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e7 (77.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e5 (23.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e12 (92.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e6 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eEngage patients in collaborative care program and introduce care team\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e17 (81.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e7 (77.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e8 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e11 (78.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e10 (47.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e10 (76.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e4 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e4 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e4 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 689px;\" colspan=\"7\"\u003e\n\u003cp\u003e\u003cstrong\u003eTrack Treatment Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eTrack treatment engagement \u0026amp; adherence using registry\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e15 (71.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e12 (92.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e5 (55.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e8 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e3 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e9 (69.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e1 (11.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e2 (25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eReach out to patients who are non-adherent or disengaged\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e17 (81.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e12 (92.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e6 (75.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e9 (64.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e6 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e8 (61.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e3 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e2 (25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e1 (7.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eTrack patients\u0026rsquo; symptoms with measurement tool\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e12 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e12 (92.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e4 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e5 (28.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e9 (69.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e5 (55.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e3 (37.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eTrack medication side effects and concerns\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e13 (61.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e4 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e3 (37.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e7 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e9 (42.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e1 (11.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 113.812px;\" rowspan=\"2\"\u003e\n\u003cp\u003eTrack outcome of referrals and other treatments\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e15 (71.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e7 (77.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e8 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e8 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 83.1875px;\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 94px;\"\u003e\n\u003cp\u003e8 (38.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e4 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 104px;\"\u003e\n\u003cp\u003e2 (25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 95px;\"\u003e\n\u003cp\u003e2 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbsolute Numbers; a Answering categories were: yes; no; b Answering categories were: high; Med/low confident; \u0026lsquo;other n=1\u0026rsquo; was excluded from this analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6:\u003c/strong\u003e Team Member Self-Assessment tool: Initiate and provide treatment \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"198\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn total n=65 professionals \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u003cstrong\u003eNurse\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=21 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003ePsychiatrist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=13 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003ePsychologist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=9 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocial worker\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=8 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cstrong\u003ePeer worker\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=14 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\" width=\"690\"\u003e\n\u003cp\u003e\u003cstrong\u003eInitiate and provide treatment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003ePerform behavioural health assessment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e12 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e6 (75.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e8 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e5 (28.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (55.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3 (37.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e2 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eDevelop and update behavioural health treatment plan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e12 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e10 (71.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e3 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e2 (25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e2 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003ePatient education about symptoms and treatment option\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e14 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e9 (64.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e7 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e6 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e8 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003ePrescribe psychotropic medications\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e4 (19.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (11.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e1 (4.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (11.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003ePatient education about medications and side effects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e6 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13(100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e2 (22.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e4 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e4 (19.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e2 (22.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eBrief counselling, activity scheduling, behavioural activation\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e13 (61.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e9 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e7 (87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e8 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e7 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e6 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e2 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eEvidence-based psychotherapy\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e6 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3 (37.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e4 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8 (61.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e6 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eIdentify and treat coexisting medical conditions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e7 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e4 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3 (3339%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eFacilitate referral to specialty care or social services\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e13 (61.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e2 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e5 (28.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e2 (22.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e7 (87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eCreate and support relapse prevention plan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e17 (81.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e9 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e5 (35.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e8 (38.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e6 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbsolute Numbers; a Answering categories were: yes; no; b Answering categories were: high; Med/low confident; \u0026lsquo;other n=1\u0026rsquo; was excluded from this analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7:\u003c/strong\u003e Team Member Self-Assessment tool: Proactively adjust treatment if patients are not responding and other tasks important for our project\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"198\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn total n=65 professionals\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u003cstrong\u003eNurse\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=21 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003ePsychiatrist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=13 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003ePsychologist\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=9 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocial worker\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=8 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cstrong\u003ePeer worker\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en=14 \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\" width=\"690\"\u003e\n\u003cp\u003e\u003cstrong\u003eProactively adjust treatment if patients are not responding\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eAssess need for changes in treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e15 (71.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e7 (77.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e7 (87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e5 (35.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e4 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e12 (92.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eFacilitate changes in treatment/ treatment plan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e15 (71.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e9 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e7 (87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e5 (35.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e5 (28.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e10 (76.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eProvide caseload-focused psychiatric consultation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e13 (61.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e6 (42.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e6 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e2 (5.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e2 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eProvide in-person psychiatric assessment when needed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e12 (57.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e5 (23.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e13 (100.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e1 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\" width=\"690\"\u003e\n\u003cp\u003e\u003cstrong\u003eOther tasks important for this program \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eCoordinate communication among team members/ providers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e11 (52.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6 %)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e8 (88.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (62.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e7 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e4 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e9 (69.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (55.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3 (37.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e3 (21.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eAdministrative support for program (e.g., scheduling, resources)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e15 (71.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e11 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e6 (66.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e7 (87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e7 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e4 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e9 (69.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e2 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eClinical supervision for Program\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eIs this my role\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e10 (47.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e12 (92.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5 (55.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e4 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e7 (50.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eHighly confident\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e5 (23.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e12 (92.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3 (33.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e3 (21.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbsolute Numbers; a Answering categories were: yes; no; b Answering categories were: high; Med/low confident; \u0026lsquo;other n=1\u0026rsquo; was excluded from this analysis\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community mental health services, Implementation, Collaborative Teamwork, Role perceptions ","lastPublishedDoi":"10.21203/rs.3.rs-215308/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-215308/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e CMHTs deliver healthcare that supports the recovery of people with mental illness. They should achieve a sufficient level of good quality teamwork, composed of individual professional skills as well their adaptation within the clearly defined roles in teams in order to work efficiently. This paper analyses to what extent team members of five CMHTs newly implemented in five countries had introduced aspects of the recovery-oriented approach and evaluates what the team members’ perceptions on their collaborative care roles and their level of confidence with this role are.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: A quantitative survey was administered among 66 professionals and peer worker including the Recovery Self-Assessment Tool Provider Version (RSA-P), the Team Member Self-Assessment Tool (TMSA), and demographic questions. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResult:\u003c/strong\u003e The RSA-P showed that all teams had the perception that they provide recovery–oriented practice to a moderately high degree after a training week on recovery-oriented care. Healthcare providers with fewer years of professional experience perceived more frequently that they operated in a recovery-oriented way (p=0.036, B -0.268). Nurses and peer workers did not feel confident or responsible to fulfil specific roles.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Trainings on community-based practices and collaborative teamwork may facilitates recovery-oriented care and helps to improve team cohesion.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eEach trial was registered before participant enrolment in the clinicaltrials.gov database: Croatia, Zagreb (Trial Reg. No. NCT03862209); Montenegro, Kotor (Trial Reg. No. NCT03837340); Romania, Suceava (Trial Reg. No. NCT03884933); Macedonia, Skopje (Trial Reg. No. NCT03892473); Bulgaria, Sofia (Trial Reg. No. NCT03922425)\u003c/p\u003e","manuscriptTitle":"Recovery-oriented practices and role perceptions of healthcare staff providing community-based mental healthcare as team in Central and Eastern Europe: an observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-02-11 22:27:32","doi":"10.21203/rs.3.rs-215308/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-04-22T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-20T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThe article focuses on an important issue within the transformation of mental health systems towards a recovery approach in Central and Eastern Europe.\nHowever, deducing from responses of staff members of the newly formed CMHT in 5 cities within the region of their readiness to engage in recovery activities and level of confidence in doing so following one week of training about the recovery appraoch is unlikely to be sufficient to establish any real change in knowledge, attitudes, and appropriate actions.\nFuthermore, it is surprising that no attention is paid in the article to the deinstitutionalisation phase that each of these services has either already been involved with or would need to be involved with in the near future.\nThis process has considerable implications to what would be required from the CMHTs, which would include a re-assement of past activities with service users moving out of the instittuion, often after many years of being there.\nThe finding that the staff with fewer years of working experience are more keen to engage in recovery activities makes good sense, given that the move to a recovery appraoch requires attitudinal change by staff, including the recognition that past non-recovery practice has not followed the principles of the recovery approach, which are necessary for achieving a meaningful life with and byond mental illness.\nAn observational study of current practices of the CMHT would be likley to demonstrate the degree of focus on recovery based activities in these CMHTs.\nThe authors recognise some of the limitations highligted above, but not all of them.\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-04-18T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-02-26T00:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\n27.2.21\nBMC Psychiatry\nRecovery-oriented practices and role perceptions of healthcare staff providing\ncommunity-based mental healthcare as team in Central and Eastern Europe: an observational study\n\nTitle: The abstract states that this is an observational study; it clearly isn't.\n\nOverall: Clearly some good work at the roots of this study. However, it does not consider consumer perspective or consumer literature. Does not establish what the recovery-oriented elements are in the intervention - this sounds more like collaborative care - as a result perhaps the title should be revised. The references should be revised to include contemporary pieces, many are for 2007 or older. Strengths include reporting the a peer worker assisted in the development of training and the use of a multi-site international study of addressing communities which we may not know much about. This is a very valuable study and I wish the authors good luck in this papers evolution.\n\nAbstract:\n1. Background, sentence 1 and 3. \"CMHST\" should be spelled out in full instead of using an acronym\n2. Background. I think this should be in past tense e.g. revise analyses\n3. Methods, sentence 1. I think it should be peer workers, the S is missing.\n4. Method should state the total number of participants per cohort.\n5. Methods should state who the \"professionals\" are.\n6. Methods please state if these measures are self reported\n7. The title says that this is an observational study; this is not reported in the abstract. If it is observational, which method does it use?\n8. The methods should indicate how the results will be analysed\n9. Results: the is an extra space after \"Results:\"\n10. The results are unclear. Can you please state how they were analysed and what the results were, including any significant findings\n11. The conclusion is currently not supported by the method or the findings\n12. Overall, it has not yet established what the study is doing or how the back ground, research problem, methods, results and discussion/conclusion are linked.\n13. The aim/objective is not clearly stated.\n14. This abstract needs to clarify if it is measuring the perception of recovery-oriented practice (ROP) or evaluating this objectively (i.e. impact)\n\nBackground:\n1. All: The author should decided which term they are going to use i.e.. Mental disorder or mental illness and apply this consistently through the paper.\n2. Paragraph 1. The author should specify how these statistics may vary according to different countries and economies; these statistics may not be a good representation of this impact different places/populations. It is important that these statistics reflect the countries/populations which were the setting for this study\n3. Paragraph 2: It would be good to state what evidence there is about the acceptability and effectiveness of ACT and FACT teams; other key community mental health interventions should be critically evaluated here, FACT is only one example. There should be more than one reference cited for FACT, it has a strong body of literature behind it\n4. Paragraph 3: I would revise the use of the term patient to something recovery-oriented such as consumer\n5. Paragraph 3: Recovery is an umbrella term - it is not always specific to SMI.\n6. Paragraph 3: SMI should be defined in its first use\n7. Paragraph 4: The authors are contradicting themselves, personal recovery is always in the consumers hands - do they mean the management of clinical symptoms; this should be stated\n8. Overall, the order of the content should be revised to that a strong and clear case for community mental health treatment is made and it distinguishes personal recovery (which is sovereign to the consumer) and clinical recovery which can be supported by staff.\n\nMethods:\n1. Participants, sentence one: Should read \"18 years of age\"\n2. \"Peer worker\" should be revised throughout the MS to make sure that it shouldn't be pluralised\n3. Can you confirm that all peer workers had the lived experience of SMI; how would you know is it in their role description. Or could they have had less intense experiences (anxiety/depression)\n4. The exclusion criteria are a little unusual. Why wouldn't a professional be able to give consent? It may be helpful to clearly indicate the inclusion/exclusion criteria by stating this e.g. Our inclusion criteria were….\n5. I can't see the ethics approval details including where it was approved or its unique identifier; this is recorded later on but should be included here.\n6. A section on 'Setting' should be added\n7. The project title RECOVER-E should be introduced earlier to help connect the reader to the project. This is the name of the program, yes?\n8. Training in ROP: Although skill training is important is not necessarily ROP. How was this ROP as opposed to good collaborative care? This is very important as it is the key premise of the paper and is in the title\n9. Sociodemographic questionnaire: In the future it is recommended that you inquire into gender not sex. Please correct if this is just a matter of expression.\n\nResults:\n1. Throughout: Please revise the use of the term \"majority\" or \"few\" and similar other expressions, instead can you please report the actual number and/or percent\n2. It is incorrect to report a figure as (n=60%) n= refers to the number of participants. It would be more specific to report it as…e.g. \"7 peer workers (38%)\" or (n=7; 38%)\n\nDiscussion: \n1. Sentence 1: This is the first time the aim is stated, the secondary aim is stated later on. The secondary aim should be identified as not being the primary aim earlier in the MS. This study does not fulfill this aim as it does not measure the degree to which the participants bring ROP in to their community, this would require an external or objective measurement. Perhaps, what is more in line is that the study explores the perceptions of the participants with regard to their practice. This paragraph is repeating information and is not a discussion of the implications and results.\n2. Paragraph 2 repeats the results and does not contextualize it within existing literature or practice\n3. Paragraph 3: discusses how ROP has been introduced but I'm not seeing what aspect of ROP have been included in the training or practice (i.e. hope, self determination). I feel like this is better described as collaborative practice rather then ROP\n4. Implications for practice are not supported by the findings \n5. Strengths and limitations: I disagree that there was a high number of participants\n6. Authors are now calling this a descriptive study - I don't agree with this\n7. Significant revision of the discussion is required to contextualize the findings and draw out the implications. Contemporary citations should be found to explore this.\n\n\nConclusions:\n1. I don't think the conclusion is supported by the findings or entirely reflective of the aim\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **none**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorAssigned","content":"","date":"2021-02-07T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-02-07T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-02-07T00:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2021-02-06T23:06:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-02-04T00:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-12-20T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d5bd4df8-f4b6-44e0-8f38-5f1b8a9952b3","owner":[],"postedDate":"February 11th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":2343113,"name":"Psychiatry"}],"tags":[],"updatedAt":"2021-02-11T22:27:32+00:00","versionOfRecord":[],"versionCreatedAt":"2021-02-11 22:27:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-215308","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-215308","identity":"rs-215308","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}